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PRO Review Soultions and Tutorial Diagnostics

4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

TABLE OF CONTENTS

I. Psychiatric Nursing, 3
II. Basic Principles of Psychiatric Nursing, 3
III.3 Levels of Psychiatric Nursing (Levels of Health), 3
a. Primary, 3
b. Secondary, 4
c. Tertiary, 6
IV. Criteria of Mental Health, 6
V. Components of Assessment of Mental Status, 6
VI. DSM V (Diagnostic and Statistical Manual for Mental Health, 7
VII. Conceptual Models of Psychiatric Treatment, 7
VIII. Psychosocial Theory of Eric Erikson, 7
IX. Psychosexual (Psychoanalytical) Theory of Sigmund Freud, 7
a. Freudian Theory Component, 8
X. Essential Elements of Nurse-Client Contact, 9
XI. Four Phases of Nurse-Client Contact, 10
a. Pre-interaction/Pre-orientation, 10
b. Orientation, 10
c. Working Phase,11
d. Termination, 11

XII. Therapeutic Communication, 11


a. Therapeutic Communication Techniques, 11
b. Blocks to Therapeutic Communication, 12

XIII. Behavioral Therapy, 13


A. Terminologies, 13
a. Classical Conditioning, 13
b. Operant Conditioning, 14
c. Behavioral Treatments, 16
XIV. Group Therapy, 16
A. Definition, 16
B. Types of Groups, 16
C. Advantage of Group Therapy, 17
D. Principles of Group Therapy, 17
E. Phases of Group Therapy, 17
XV. Defense Mechanisms, 18
XVI. Anxiety, 20
A. Definition, 20
B. Major Assessment criterion for Measuring Degree of Anxiety, 20
C. Potential Nursing Diagnosis, 21
D. Nursing Intervention, 21
XVII. Types of Anxiety Disorder, 22
A. Phobia and Panic Disorder, 22
B. Obsessive-Compulsive Disorder, 22
C. Post Traumatic Stress Disorder, 23
D. Anxiolytic/Anti-Anxiety Drugs, 24
a. Benzodiazepine, 24
b. Barbiturates, 24
c. Atypical Anxiolytics, 25
XVIII. Psychotic Disorder: Schizophrenia, 25
A. Assessment Finding: General Signs, 25
B. Prioritized Nursing Diagnoses for all types of Schizophrenia, 27
C. Five Types of Schizophrenia, 27
D. Principle of Care in Schizophrenia, 28
XIX. Antipsychotics, 28
A. Phenothiazine, 28
B. Butyrophenones, 29
C. Thioxanthenes, 29
D. Atypical Anxiolytics, 29
E. Six Common Anticholinergic Side Effects of Antipsychotics, 29
F. Acute/Common side Effect for Prolonged use of Antipsychotics,30
G. Anti-Extrapyramidal Medications, 31
H. Adverse Effects of Antipsychotic Drugs, 31
XX. Affective/ Mood Disorder, 31

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 1


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

A. Types
I. Depressive Disorder, 31
a Antidepressants/ Thymoleptics, 34
i. Selective Serotonin Reuptake Inhibitors (SSRI), 34
ii. 2nd Generation Tricyclic Antidepressants (TCA), 35
iii. MAOI-Monoamine Oxidase Inhibitor, 36
iv. Electro Convulsive Therapy (ECT), 36
II. Bipolar Disorder, 38
a. Mood Stabilizers, 40
XXI. Psychosomatic/ Somatoform Disorder, 42
A. Psychosomatic Disorders, 42
B. Types of Somatoform Disorder/Psychosomatic Disorders, 43
XXII. Dissociative Disorder, 44
XXIII. Personality Disorders, 44
A. Cluster A: ODD/Eccentric, 45
a. Paranoid Personality Disorder, 45
b. Schizoid Personality Disorder, 45
c. Schizotypal Personality Disorder, 46
B. Cluster B: Dramatic/Erratic, 46
a. Antisocial Personality Disorder, 46
b. Borderline Personality Disorder, 47
c. Histrionic Personality Disorder, 47
d. Narcissistic personality Disorder, 47
C. Cluster C: Anxious/ Fearful, 48
a. Obsessive-Compulsive Disorder, 48
b. Dependent Personality Disorder, 49
c. Avoidant Personality Disorder, 49
d. Passive-Aggressive Personality Disorder, 49
XXIV: Cognitive/ Organic Mental Disorder, 49
A. Delirium vs. Dementia, 50
B. Types of Dementia
C. Alzheimer’s Disease, 50
XXV. Eating Disorders, 55
A. Anorexia vs. Bulimia, 55
XXVI. Drug Addiction/Non-Alcoholic Substance Abuse, 57
A. Non-Alcoholic Abused Substances, 57
XXVII. Sexual Disorder/ Dysfunction, 59
XXVIII. Pervasive Developmental Disorder, 60
A. Autistic Disorder, 60
B. Attention Deficit Hyperactive Disorder, 61
C. Child Abuse, 61

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 2


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

PSYCHIATRIC NURSING

• A specialized area of nursing practice employing theories of human behavior as its science and purposely use of self as its art.
Includes the continuous and comprehensive services necessary for the promotion of optimal mental health, prevention of mental illness,
health maintenance, management and referral of mental and physical health problems, the diagnosis and treatment of mental disorders
and their sequela, and rehabilitation

BASIC PRINCIPLES OF PSYCHIATRIC NURSING

 Accept and respect the client regardless of his behavior.


 Limit or reject the inappropriate behavior but not the individual
 Encourage and support expression of feelings in a safe and non-judgmental environment. Increase verbalization, decreases anxiety.
 Behaviors are learned.
 All behavior has meaning.

INTERDISCIPLINARY TEAM PRIMARY ROLES

• Psychiatrist: The psychiatrist is a physician certified in psychiatry by the American Board of Psychiatry and Neurology,
which requires 3-year residency, 2-years of clinical practice, and completion of an examination. The primary function of
the psychiatrist is diagnosis of, mental disorders and prescription of medical treatments.
• Psychologist: The clinical psychologist has a doctorate (Ph.D.) in clinical psychology and is prepared to practice therapy,
conduct research, and interpret psychological tests. Psychologists may also participate in the design of therapy programs
for groups of individuals.
• Psychiatric nurse: The registered nurse gains experience in working with clients with psychiatric disorders after
graduation from an accredited program of nursing and completion of the licensure examination. The nurse has a solid
foundation in health promotion, illness prevention, and rehabilitation in all areas, allowing him or her to view the client
holistically. The nurse is also an essential team member in evaluating the effectiveness of medical treatment, particularly
medications. Registered nurses who obtain a master’s degree in mental health may be certified as clinical specialist or
licensed as advanced practitioners, depending on individual state nurse practice acts. Advanced practice nurses are certified
to prescribe drugs in many states.
• Psychiatric social worker: Most psychiatric social workers are prepared at the master’s level, and they are licensed in some
states. Social workers may practice therapy and often have the primary responsibility for working with families,
community support, and referral.

• Occupational therapist: Occupational therapist may have an associate degree (certified occupational therapy assistant) or a
baccalaureate degree (certified occupational therapist). Occupational therapy focuses on the functional abilities of the client
and ways to improve client functioning such as working with arts and crafts and focusing on psychomotor skills.

• Recreation therapist: Many recreation therapists complete a baccalaureate degree, but in some instances persons with
experience fulfill these roles. The recreation therapist helps the client to achieve a balance of work and play in his or her
life and provides activities that promote constructive use of leisure or unstructured time.

• Vocational rehabilitation specialist: Vocational rehabilitation includes determining clients’ interests and abilities and
matching them with vocational choices. Clients are also assisted in job-seeking and job-retention skills, as well as pursuit
of further education if that is needed and desired. Vocational rehabilitation specialists can be prepared at the baccalaureate
or master’s level and may have different levels of autonomy and program supervision based on their education.

3 LEVELS OF PSYCHIATRIC NURSING (Levels of Health)

I. PrimaryObjective: PROMOTION & PREVENTION

A. Client and Family Teaching (Health Teaching)

1. Teaching adolescent in preventing contracting STDs

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 3


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

CHLAMYDIA: #1 STD in the U.S.


#1 Sign: Greenish & purulent urethral discharge.
PID (Pelvic Inflammatory disease) #1 cause of sterility in women

#1 Drug of choice Erythromycin


2nd drug of choice Cephalosporin

2. Teaching pregnant women relaxation techniques


Objective: to prevent complication in labor, fetal distress, perineal laceration (also can be prevented by Kegel’s
exercise)

Stage I of labor (LAT-CAP)


L atent C chest breathing
A ctive A bdominal breathing
T ransitional P ant blow breathing

3. Teaching couples on contraceptives


BON (Barrier, Oral Contraceptive, Natural)
Barrier - CONDOM
Oral - Artificial
Natural - not for M A M (Malnourished, Anemics
& Menses irregular)
4. Conducting rape prevention classes is an example of primary level of prevention.

B. Herbal Medicines

C. Psychosocial Support – family/friends/peers


Needs most support (ASA): Addicts, Suicidal, Alcoholics,
Suicide = Major depression, despair, hopeless, powerless

Prone: Male Age bracket prone for suicide


#1. Adolescent (identity crisis)
2. Elderly (ego-despair)
3. Middle age men (40 y.o. above)
4. Post partum depression (7 days/2-4 weeks)

D. Giving Vaccines

II. Secondary : Screening, Diagnosis & Immediate Treatment


A. Screening
> Denver Development Screening Test (DDST) #1 test for PDD

Pervasive Development Disorder (PPD)

1. Autism: Age of onset (3 y.o.)


2. ADHD: Age of onset (6 y.o.)
Diet: Finger Food (high caloric, high CHO)
Rx: Ritalin (Methylphenidate); dextroamphetamine (Dexedrine)
3. Conduct disorder: Age of onset (6 y.o.)

B. Suicide Prevention/Intervention

Impending signs of Suicide


1. Sudden elevation of mood/sudden mood swings
2. Giving away of prized possessions
3. Delusion of Omnipotence (divine powers)
Used by SS (Suicidal, Schizophrenia)
4. When the patient verbalizes that the 2 nd Gen TCA is working.
less than 2-4 wks (telling a lie)

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 4


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

Suicide Interventions:
1. One-on-one supervision and monitoring
2. No suicide contract – 24 hrs monitoring
- Patient is required to verbalize suicidal ideas
3. Non metallic/plastic/sharp objects: ex. belts, curtains
4. Avoid dark places

C. Case Finding (Epidemics)/Contact Tracing (STDs)

D. Crisis Intervention

Objective: To return the client to its normal functioning or pre crisis level.
Duration: (4-6 wks)
Disorganization is a phase in the crisis state which is characterized by the feelings of great
anxiety
and inability to perform activities of daily living

A patient in crisis is passive and submissive, so the nurse needs to be active and should
direct the
paient to activities that facilitate coping.

Types of Crisis:

1. Developmental Maturation Crisis


- Adolescence (identity crisis)
- Mid-life crisis;
- Pregnancy
- Parenthood

2. Situational / Accidental crisis –


- Most common: Death of a loved one
NSG DX: Ineffective Individual Coping/ Denial
- ex. murder, abortion , rape and fire

3. Adventitious – calamity, disaster


ex. World War I & II, epidemic, tsunami
In a DISASTER 1st assess/survey the scene

E. Emergency drugs and antidotes

DRUGS/ DISEASE Action / Effect ANTIDOTES


Heparin Anticoagulant Protamine Sulfate
Warfarin (Coumadin) Anticoagulant Vit. K
Mg Sulfate Anticonvulsants Calcium gluconate
Nubain (best), Morphine Narcotics Naloxone (Narcan)
Fibrinolytic / Thrombolytic Dissolves clot Amicar (Aminocaproic acid)
*(Neuroleptic Malignant Syndrome’s #1 Cardinal Sign : High Fever / Dantrolene (Dantrium), Bromocriptine
(NMS) Hyperthermia (Parlodel)
Effect: antiparkinsonian, anti-prolactin,
antipsychotic
Hypertensive crisis (MAOI intoxication) Antidepressant intoxication Ca channel blocker
Suffix:(-dipine)
Anxiolytics, Sedatives – Sedative hypnotic/ Minor tranquilizer Flumazenil (Romazicon)
Suffix: zepam, -zolam
Tensilon (Endrophonium): Anticholinesterase & Miotic Atropine Sulfate (ATSO4)
Anticholinesterase intoxication,
Pilorcarpine (Pilocar) intoxication :
Miotic

III. Tertiary Objective: Rehabilitation, which start upon admission


A. Occupational Therapy –
- Usually use behavior modification for PDD (Pervasive Developmental Disorders),
anorexia & depression
- Also use fine motor rehabilitation for Post M.I. & Post CVA
B. Vocational Skills (Entrepreneur skills)
C. Aftercare Support – follow-up.
Needed by: addicts & residual schizophrenia due to remission & exacerbation

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 5


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

CRITERIA OF MENTAL HEALTH


(Jahoda, 1953; Staurt and Sundeen, 1995)

• Reality perception: Ability to test assumptions about the world by empirical thought; includes social sensitivity (empathy)
• Growth, development, & self-actualization (by Maslow) which includes fully functioning person” (by Rogers)
• Autonomy: Involves self- determination, self- responsible for decisions, balance between dependence and independence, and
acceptance of the consequences of one’s action
• Positive attitudes toward self; includes self-identity, self-acceptance, self-awareness, belongingness, security and wholeness

COMPONENTS OF ASSESSMENT OF MENTAL STATUS


SENSORIUM: Consciousness? Orientation? Attention?
Concentration? Comprehension?
Example: Disorientation & Confusion ( Dementia)
APPEARANCE: Appropriateness? Grooming? Rigidity?
Mannerisms?
Example: Poor Grooming (Suicidal Patients, Schizophrenia and Manic Depression)
AFFECT / MOOD: Appropriateness? Swing? Duration? Intensity?
Example: Flat Affect: Schizophrenia & Major Depression. Seen also in Parkinson’s Disease
& Myasthenia Gravis.
Labile Affect: Manic Depression or Bipolar Disorder
THOUGHT CONTENT: Self-concept? Areas of concern? Themes? Obsessions? Delusions? Hallucinations?
Example: Delusion of grandeur (manic), delusion of omnipotence ( schizophrenia), delusion
of persecution & delusion of reference (paranoid delusions)
THOUGHT PROCESS: Ability to understanding abstract/symbols?
Example: Magical thinking and animism of Schizotypal personality
SPEECH: Coherency? Relevance? Meaning? Quality/Quantity?
Example : Slurring of Speech ( alcoholism) and pressured speech (manic depression or
bipolar disorder)

DSM V (Diagnostic and Statistical Manual for Mental Health)

Axis I Clinical Syndrome (S&Sx)


II Personality Disorders
III Pathological Disorders
IV Environmental & Psychosocial stressors
V Global Functioning (assessment)]

CONCEPTUAL MODELS OF PSYCHIATRIC TREATMENT

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 6


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

• PSYCHOANALYTICAL/PSYCHOSEXUAL MODEL. (Freud); Focus- Intrapsychic process (conflicts, anxiety, defense mechanisms,
impulses).
• BEHAVIORAL FRAMEWORK: Focus- learned behavior; Pavlov’s Theory: Classical Conditioning; Skinner’s Theory: Operant
Conditioning.
• INTERPERSOAL MODEL (Sullivan and Peplau); Focus- Interpersonal relationships
• PSYCHOSOCIAL THEORY (Erik Erickson); Focus-Psychosocial tasks
• EXISTENTIAL MODEL / HUMANISTIC MODEL (Rogers); Focus- Conscious human experiences
• BIOMEDICAL MODEL (Meyer, Kraeplin, Frances); Focus – Disease approach, syndromes, diagnoses, etiologies.

PSYCHOSOCIAL THEORY OF ERIC ERIKSON

• Most commonly used theory by health professionals.


• Describes the human cycle as a series of eight EGO developmental stages from birth to death; Focus: PSYCHOSOCIAL TASKS
throughout the life cycle.
• STAGES OF PSYCHOSOCIAL DEVELOPMENT:

AGE PSYCHOSOCIAL TASKS


Infancy (0-18 mo) Trust vs. Mistrust
Toddler (18 mo-3 yrs) Autonomy vs. Shame and Doubt
Preschool Age (3-6 yrs) Initiative vs. Guilt
School Age (6-12 yrs) Industry vs. Inferiority
Adolescence (12-20 yrs) Identity vs. Role confusion
Early Adulthood (20-35 yrs) Intimacy vs. Isolation
Middle Adulthood (35-65 yrs) Generativity vs. Stagnation
Most common task of 40 y/o includes
developing responsibility over their own
lives
Later years / Old Age (65 yrs) Integrity vs. Despair
76 y/o male who has a good ego integrity is
preoccupied w/ death

PSYCHOSEXUAL (PSYCHOANALYTICAL) THEORY


OF SIGMUND FREUD

• Infancy: Oral Phase; Stage of the Id


• Toddler: Anal Phase; Stage of the Ego
• Preschooler: Phallic Phase; Stage of the Superego (conscience)
 Attachment of the child to the parent of the opposite sex and jealousy toward the parent of the same sex
 Oedipal Complex: Attachment of the son to his mother and jealousy toward the father.
 Electra Complex: Attachment of the girl to her father and jealousy toward the mother.
• Schooler: Latency phase; Stage of the Strict Superego
• Adolescent: Genital phase

FREUDIAN THEORY COMPONENTS:


1. LEVELS OF AWARENESS:

Conscious
Subconscious
Watchman of the Personality
Unconscious
The one who molds the personality
Storage bin of traumatic & meaningful memories. True desires
& motives are here.

• Conscious – Composed of past experiences, logical and governed by REALITY PRINCIPLE; are remembered and easily
recalled or available to the individual

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 7


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

• Subconscious – the Preconscious; composed of material that has been deliberately pushed out of conscious level; helps repress
unpleasant thoughts or feelings and can examine or censor certain desires or thinking; can be recalled with some effort
• Unconscious – Composed of the LARGEST BODY OF MATERIAL- the thoughts, memories and feelings that are repressed and
not available to the conscious mind, not logical and governed by PLEASURE PRINCIPLE – and since it is usually painful and
unacceptable to the individual, it cannot be deliberately brought unacceptable to the individual, it cannot be deliberately brought
back into awareness unless in disguised or distorted form (dreams)

2. SYSTEMS OF PERSONALITY, 3 AGENCIES OF THE MIND:

Three Elements of Personality

FUNCTION PRINCIPLE LANGUAGE PERSONALITY


Id -Animal instinct -Pleasure Principle “I want it when I want Infant/child
-Survival of the fittest it.”

Ego -Balances (Mediator) Reality Principle “I can wait.” Adult


the desire of the Id and
Superego
The ego acts as
the integrator of
the personality.
Superego -Induces guilt  Conscience Principle “Thou shall not.” Parent
undoing

IMBALANCE or ABNORMAL FUNCTIONING OF THE THREE ELEMENTS


OF PERSONALITY

↑Id + ↓SE = Conduct Disorder and Antisocial Personality Disorder


↓Id + ↑SE = Obsessive Compulsive Disorder

• ID: Psychoanalytic term for that part of the psyche that is UNCONSCIOUS, the reservoir of INSTINCTS, primitive drives
governed by the PLEASURE PRINCIPLE and is SELF- CENTERED. The Ids says, “I want, what I want, when I want it”.
• EGO: Psychoanalytic term for that part of the psyche that is CONSCIOUS, The “I” that is shown to the environment and most in
touch with REALITY and the MEDIATOR between the primitive, pleasure- seeking, instinctive drives of the ID and the self-
critical, prohibitive forces of the SUPEREGO and is directed by REALITY PRINCIPLE. This is the thinking- feeling part of
personality. The Ego says, “I would want to have it if only I can afford it;” “Not now, I am not yet ready; perhaps next week.”
• SUPEREGO: Psychoanalytic term for that part of the psyche that RESTRAINS, controls, inhibits and prohibits impulses and
instincts, is self- critical, and is called the CONSCIENCE or EGO IDEAL. The Superego says, “I should not want that; It is not
good to even wish for it.”

ESSENTIAL ELEMENTS OF A NURSE- CLIENT CONTRACT


1. Names of RN and patient 5. Purpose of a relationship
2. Roles of RN and patient 6. Meeting location / time
3. Responsibilities of RN and patient 7. Condition for termination
4. Goals / Expectations 8. Confidentiality

FOUR PHASES OF NURSE- CLIENT RELATIONSHIP (NCR)

A. Pre-interaction/Pre-orientation (For the Nurse)


- Stage of Self-Awareness  To prevent Counter Transference
#1 CORE VALUE OF Psychiatric Nursing

B. ORIENTATION (INITIATION)

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 8


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

Assessment of problems, needs, expectations of clients


Identify anxiety level of self and client
Set goals of relationship.
Define responsibilities of nurse and client. Stage of testing.
Establish boundaries of relationship. Stress confidentiality.

Contract – 2 famous psychiatric contracts:

1. No suicide contract  Major depression = emergency

TWO definitions of no suicide contract:


A. 24 hrs monitoring
B. Verbalization to the nurse of all suicide ideas

2. Diet contract  Eating disorder

- The start of termination phase: “Good morning, full name, RN, shift, session, date start & end.”

C. WORKING PHASE

 Promote acceptance of each other


 Accept client as having value and worth as a unique individual.
- Stage of resistance
- Counter transference phase
- Most difficult phase
-- NCP is on going
- Identification of the problem/exploration
- The #1 Psychiatric Core Value is Consistency  For manipulative patients
Be consistent to patient with: BAAAM COPS
B orderline C onduct d/o
A ntisocial O ral/eating disorder
A lzheimer’s P aranoid
A utistic S uicidal
 M anic
 Use therapeutic and problem- solving techniques
 Maintain PROFESSIONAL, therapeutic relationship
 Keep interaction reality- oriented- here and now
 Provide ACTIVE LISTENING and REFLECTION of feelings
 Use non- verbal communication to support client
 Recognize blocks to communication and work to remove them
 FOCUS on client’s:
 Confronting and working through identified problems
 Problems- solving skills
 Increasing independence
ο Help client develop alternative, adaptive coping mechanisms

Personal biases (manifestation by counter-transference & vice versa) are seen


during working phase

D. TERMINATION
 Plan for termination of relationship early the relationship
- Stage of Separation Anxiety 
Signs & symptoms: Regression: Temper tantrums, thumb sucking, apathy, fetal position when crying.
- Phase of prognosis  Evaluation
 Maintain boundaries
 Anticipate problems of termination:
ο Increased dependency on the nurse
ο Recall of previous negative experience- rejection, depression, abandonment, etc.
ο Regressive behaviors
 Discuss client’s feelings and objectives achieved

THERAPEUTIC COMMUNICATION

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 9


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

 DEFINITION: Continuous, dynamic process of SENDING and RECEIVING MESSAGES by various verbal or non- verbal
means (words, signals, signs, symbols) utilized in a goal- directed professional framework.

THERAPEUTIC COMMUNICATION TECHNIQUES

a. Offering of self – safety, service, comfort


“I am here. I will sit here beside you.
I will lead you to the group therapy session.”
*Ursula, age 25, is found on the floor of the bathroom in the day treatment cleaning with
moderate lacerations to both wrists. Surrounded by broken glass, she sits staring blanking at
her bleeding wrist while staff members call for an ambulance. The best way the nurse should do
is to approach Ursula slowly while speaking in the calm voice, calling her name and telling her
that the nurse is here to help her. This approach provides reassurance for a patient in distress.

b. Reflection: (mirror of feelings) “It must be difficult for you.” “You seem angry. You seem concerned.”
When patient with symptoms of severe depression says to the nurse “I can’t talk; I have nothing
to say.” And continues being silent. The most appropriate response of the nurse is to say, “It
may difficult for you to speak at this time; perhaps you can do so at another time”. This
response will convey that the nurse is willing to wait for the patient’s readiness to engage in
conversation.

Daughter of patient newly diagnosed w/ Alzheimer’s says, “I can’t be. Nobody in the family
is senile,” correct 5response of RN includes statement like, “It sounds as if you are shocked
over the diagnosis.”

c. Elaboration/Exploration
“Tell me more about your feelings”
“Everyone is on my back. My husband says, ‘I don’t do anything right,’ & my boss wants
me to do things differently.” RN’s response to elaborate feelings includes statement like,

“Have you discussed this with your husband about how to cope with these problems?
Tell me.”

Appropriate response for an 80 y/o who says, “I told my children that I’m ready to die.”
Includes statement like “Tell me about your feelings & I will stay w/ you.”

d. Clarification – used in neologism and word salad SAM (seen in Schizophrenia, Alzheimer’s, Manic)

“What do you mean by…?” (Used in Neologism and word salad)

“I could not follow you.” –


(Used in flight of ideas and looseness of association)
“The ground is watching us.”, appropriate intervention includes clarify the meaning
of the word.

Brilliant & charming patient says, “I’ll be better off dead.” Best response of the RN
includes asking questions like, “Do you have plans of suicide”?

Pt says, “I’d like to take you out & give you a good show.” best response by the RN is
asking pt, “What do you mean by a good show?”

e. Reality Orientation/Reality Testing


- Nsg Dx: Altered Sensory Perception
- Delusion; Hallucination, Illusion & delusion
Client: “Help! Help! There are spiders on my back!”
Nurse: “I don’t see spiders but for you that is real.”
Alcoholic pt with delirium tremens states, “There are spiders crawling on my back”.
The appropriate response of the nurse would be, “there are no spiders, its only part of
your illness”.

f. Giving Leads
“Aha..then…mmmh… go on… yes…”

g. Therapeutic Silence

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 10


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

h. Paraphrasing/restating – repeating
Repeats the MAIN IDEA; restate what the client says. (Patient: “I can’t believe I cannot go home today.” Nurse: “You can’t believe
that you can’t go home today?”)’

i. Summarizing – recap
Nurse: “Today you have described your understanding of how you feel when you are upset with your son.”

j. Validation – interpret
Client: “I see a shadow.”
Nurse: “You’re frightened.”
A patient admitted to be listening to voices should be assessed by asking, “What does the
voice
tells you?”
“I know that Prof. Draper tried to rape me, rape my mind...& he’s still trying to rape me”,
correct of
RN includes questions like “Are you frightened being unable to control your thoughts?”
Post-menopausal woman says, “I’m pregnant by God in heaven.” Appropriate response by
the
nurse includes statement like, “You believe something special happened to you?’

“It must be frightening to feel that way.” is an appropriate response for a suspicious pt
saying, “I think that my food is being poisoned”

RN’s correct response of pt w/. OCD who checks door 10-15 times includes statement
like, “It sounds as if you have much anxiety.”

k. Open-ended question / broad openings


Questions NOT answerable by ‘YES’ or ‘NO’; encourages further or broadened communication.

“How are you?” “How’s your day?” “What are your favorite things?”

BLOCKS TO THERAPEUTIC COMMUNICATION

a. Never use why – it demands an explanation and also anxiety provoking

b. Closed Ended Question – questions answered by “yes” or “no”


Note: The only therapeutic closed-ended question  Suicidal pt.
“Are you planning to commit suicide?” – Confrontation

c. False Assurance
“Do not worry”  To patient who are dying & w/ incurable illness
“You have the best doctor; everything will be all right.”
“Relax that is nothing to worry about.”

d. Agree/disagree – never argue with client


“You are right in doing that.” / “You should not think that way.”

e. Belittling the patient – CHANGING THE SUBJECT

f. Non therapeutic silence/touch

g. Advising – never advise because they are sometimes persona; opinions


“I believe it would be better if you…”

h. Stereotyping

BEHAVIORAL THERAPY

A. TERMINOLOGIES
• STIMULUS: Any event affecting an individual
• PROBLEM BEHAVIOR: Deficient, excessive, condemned, unwanted behavior

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• OPERANT BEHAVIOR: Activities that are strongly influenced by events that follow them.
• TARGET BEHAVIOR: Activities that the nurse wants to develop or accelerate in the client.
• REINFORCER: A reward positively or negatively influences and strengthens desirable behaviors.
• POSITIVE REINFORCER: A desirable reward produced by specific behavior (TV time after doing homework)
• NEGATIVE REINFORCER: A negative consequence of a behavior (Spanking child for wetting the floor)

A. Classical Conditioning (pairing of two stimuli in order to gain a new learning


behavior – by Ivan Pavlov)

1. Acquisition (newly acquired behavior or the by product of classical conditioning).


2. Extinction

B. Operant conditioning – Burrhus Skinner


- used in Behavior Modification

1. Positive reinforcement (Reward Orientation)


 Token Economy – use tokens as a source of reward.
Used in eating disorders and depression
> Token economy is also effective for toddlers

2. Negative Reinforcement (Punishment Orientation)


 Aversion Therapy/Aversion Technique

Behavioral Treatments

1. Desensitization – gradual exposure to the feared object


-- #1 treatment for phobia
2. Flooding/.Implosive Therapy – sudden exposure
3. Relaxation Technique – light stroking = labor
- Purse Lip Breathing Exercise = COPD/CAL (Chronic Airflow Limitation)
4. Biofeedback – mind over matter. Ex. HPN  ↓BP, palpitations, headache
5. Guided Imagery (Child) & Visualization (Adult)

GROUP THERAPY

A. DEFINITION: Psychotherapeutic processes that occur in formally organized groups designed to change maladaptive or
undesirable behavior.
Knowledge of therapeutic modalities enhances the performance of nursing interventions during
therapy.
8-10 patients are the optimal number of patients in a group.

B. TYPES OF GROUPS

1. Structured
 Goals: Pre- determined
 Format: Clear and specific
 Factual material: Presented
 Leader: Retains control

2. Unstructured
1. Goals: Not pre- determined. Responsibility for goal is shared by group and leader
2. Format: Discussion flows according to group members’ concern
3. Materials and topics are not pre- elected.
4. Leader: Nondirective
5. Emphasis: More on FEELINGS rather than facts

C. ADVANTAGE OF GROUP THERAPY

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1. Economical: Less staff used.


2. Increased feelings of closeness→ Reduction on feelings of being alone.
3. With feedback group→
 Corrects distortions of problems
 Builds self- image and self- confidence
 Increases reality- testing opportunities
 Gives info on how one’s personality and behavior appear to others
4. With opportunities for practicing alternative behaviors and methods of coping with feelings
5. Provides attention to reality and provides development of insight into one’s problems by expressing own experiences and
listening to others in groups

D. PRINCIPLES OF GROUP THERAPY

1. Verbalization: Members express feelings and group reinforces appropriate communication.


Desired outcome of group therapy includes verbalization of feelings rather than acting
them out
2. Activity: Provides stimuli to verbalization and expression of feelings.
3. Support: Members gain support from one another through interaction, sharing and communication.
4. Change: Members have opportunity to try out new and desirable behaviors in group, supportive setting to effect change.

E. PHASES OF GROUP THERAPY

1. Initial Phase
 Formation of group
 Setting and clarification of goals and expectations
 Initial meeting, acquaintance and interaction

2. Working Phase
 Confrontation between members→ Cohesiveness
 Identification of problems→ Problem- solving processes
In a group therapy when one client says to another, “Maybe you’re taking on
someone else’s problems.” this shows that they are in the working phase

3. Termination Phase
 Evaluation of goals attainment
 Support for leave- taking

In group therapy if a client says, “Leave me alone & get away from me.”, best action
of the RN is to maintain distance from the pt.
Behavior indicating that goal is met after socialization in a group therapy includes
participation of each group member telling the leader about specific problems

DEFENSE MECHANISMS

REPRESSSION SUPPRESSION
CONVERSION DISSOCIATION/SYMBOLIZATION
IDENTIFICATION INTROJECTION
SUBLIMATION COMPENSATION
RATIONALIZATION PROJECTION
DISPLACEMENT UNDOING
SPLITTING REACTION FORMATION
REGRESSION FIXATION
INTELLECTUALIZATION ACTING-OUT
DENIAL FANTASY

DEFENSE MECHANISMS

Legend: DM means Defense Mechanism

1. REPRESSION Involuntary recall painful or unpleasant thoughts or feelings cause they are

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automatically & involuntarily pushed into one’s unconsciousness.


FORGETFULNESS  Blackout (alcoholic intoxication) blocking
(Alzheimer’s/Dementia)  Memory gaps  Confabulation = making story to fill in
memory gaps also used by Wernicke’s Korsakoff’s = ↓ Vit. B1-thiamine, 
peripheral neuritis (tingling sensation)  ↓ B6 Pyridoxine, B9 folic acid, B12  P.
anemia. Ex. Sexually abused as a child blocks the experience from her consciousness
and is confused about inability to respond sexually.
SUPPRESSION – used selective inattention (moderate Willingly or voluntarily putting unacceptable thoughts or feelings out of one’s mind
anxiety) with the ability to recall the thoughts or feelings at will.

Ex. Voluntary forgetfulness or “I rather not talk about it, right now!”
2. CONVERSION Transferring of mental conflict or emotional anxiety into physical symptom to release
#1 DM: Somatic/somatoform disease tension.
Ex. A soldier experiences sudden blindness after witnessing his best friend dying from a
grenade blast; Diarrhea before exam; suppress anger  HPN
DISSOCIATION Act of detaching of separating a strong emotionally charged conflict from one’s
#1 DM: Multiple personality= destruction of ego consciousness.
Ex. A woman raped found wandering a busy highway – traumatic amnesia.
SYMBOLIZATION – unconscious; An object, idea, or act represents another through some common aspect and carries the
#1 DM: Phobias emotional feeling associated with the other.
Ex. Engagement ring symbol of love; phobias
3. IDENTIFICATION – external Unconsciously, people use it to identify with the personality and traits of another. To
DM: Preschooler preserve one’s ego or self. Mimics/simulates external behavior , like fashion & fads
Ex. Imitator, similar to role playing
INTROJECTION – INTERNAL Attributing to oneself the good qualities of another. Incorporate feelings & emotions,
DM: Depression & counter transference values & beliefs, traits and personality. “ingestion, internalization”
Ex. Acting & dressing like Jesus Christ
4. SUBLIMATION Re-channeling of consciously intolerable or Socially Unacceptable Behaviors or
impulses into personally or socially acceptable. Modify the issue, problem is still
present and connected
Ex. An aggressive person joins debate team (behavior modification)++
COMPENSATION The act of making up for a real or imagined deficiency with a specific behavior.
Conscious or unconscious.
Problem is not connected.
Ex. An unattractive girl became a very good tennis player. - +
5. RATIONALIZATION – object Most common ego DM. Unconsciously used to justify ideas, actions and/or feelings
#1 DM: Anti-social disorder with good acceptable reasons or explanation. Irrational/illogical excuses to escape
responsibility. Rationalization is justifying one’s actions which are
based on other motives. It is usually seen among alcoholics.
Ex. It wasn’t worth it; anyway, it is all for the best. Student fails an exam, blames it on
the poor lectures.
Temporarily alleviates anxiety.
PROJECTION – person Person rejects unwanted characteristics of self and assigns them to others.Projection
#1 DM: Paranoid is attributing to others one’s unconscious wishes/fear. Usually
it is observed in paranoid patients.
Ex. Blaming others for own faults. “scapegoat”
6. DISPLACEMENT – higher to lower Mechanism that serves to transfer feelings such as frustration, hostility or anxiety from
one idea, person or object to another.
Ex. Yelling at a subordinate after being yelled at by the boss.
UNDOING OR RESTITUTION – lower to higher Negation of previous consciously intolerable action or experience to reduce or alleviate
DM: Obsessive Compulsive feelings of guilt.
Ex. Sending flowers after embarrassing her in public.
7. SPLITTING Viewing people as all good, and others as all bad
Impulsive = poor self-control
Ex. Hx of drug addicts & alcoholics
DM: Borderline (female)

REACTION FORMATION Person exaggerates or overdevelops certain actions by displaying exactly the opposite
#1 DM: Passive-aggressive personality disorder behavior, attitude, or feeling from what he or she normally would show in a given
situation. OVERCOMPENSATION. Conscious intent often altruistic. Procrastinate
Ex. Student hating her CI may act very courteously towards her.
8. REGRESSION A. temporary retreat to past levels of behavior that reduce anxiety, allow one to feel
more comfortable. Ex. A 27 year old acts like a 17 y.o. on her first date with a fellow
employee; smoking at parties  chronic regression
FIXATION Permanent or persistence into later life of interests and behavior patterns appropriate to
an early age. Without stressors
Ex. Chain smokers, alcoholics = oral fixation
9. INTELLECTUALIZATION The act of transferring emotional concerns into the intellectual sphere. Exaggeration of

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intellect. Person uses reasoning as a means to avoid confrontation. Ex. “Dear John”
Letter the groom is trying to figure out with his room mate why his fiancée changed her
mind – to avoid confronting her.
ACTING - OUT Unconscious wish turned into reality
Ex. Molested child  wants to be comforted  becomes psychologist = Oprah
10. DENIAL The unconscious refusal /avoidance to face thoughts, feelings, wishes, needs, and/or
#1DM: reality factors that are intolerable. Blocking the awareness of reality. Ex. “things will
Alcoholics, PTSD, incurable illness get better, soon”
14 y/o girl who is undergoing dialysis says, “What’s good
about this, is that after it I will look good & thin.” This
shows that the teen is denying her chronic illness
Cancer patient saying, “You might have mixed my result with
other patients,” is showing denial

FANTASY Imagined events or mental images. Wishful thinking; Temporary flight from reality to ↓
DM: Schizoid anxiety. Ex. Daydreaming. (permanent flight from reality: autism)

ANXIETY

A. DEFINITION: Effective subjective response to an imagined or real internal or external threat.


□ Perceived SUBJECTIVELY by the conscious mind is as a painful, diffuse apprehension or vague uneasiness, but the causative conflict
or threats is not in the conscious mind or awareness.
□ Low / mild level of anxiety is healthy and helps in individual growth and development.

B. MAJOR ASSESSMENT CRITERION FOR MEASURING DEGREE OF ANXIETY: Client’s ability to focus on what is happening to
him in a situation.

□ Mild: The perceptual field is wide allowing the client to focus realistically on what is happening to him. Alert senses, increased
attentiveness, and increased motivation.
□ Moderate: Another word is selective inattention. The perceptual field narrows and the client is able to partially focus on what is
happening if directed to do so and can verbalize feelings of anxiety.
□ Severe: The perceptual field is significantly reduced and the client may not be able to focus on what is happening to him and may not be
able to recognize or verbalize anxiety. All senses affected; decreased perceptual field; drained energy; Learning and
problem-solving not possible. Start of sympathetic symptoms: tachycardia, palpitations, hyperventilation (brown
paper bag to prevent Respiratory Alkalosis) and cold clammy skin.

□ Panic: The perceptual field is severely reduced and the client experiences feelings of panic and dread. Client overwhelmed and helpless;
personality may disintegrate → hallucinations and delusions. Pathological conditions requiring immediate intervention.
Client may harm self or others.
A patient stating, “Sometimes I feel like I’m going crazy & losing control over myself,”
is showing symptoms of panic attack

POTENTIAL NURSING DIAGNOSES


□ Ineffective Individual Coping
□ Anxiety

C. NURSING INTERVENTION IMPLEMENTATON:


□ Identify anxious behavior and anxiety levels and institute measures to decrease anxiety at a level where learning can occur.
□ Provide appropriate environment where environmental stress & stimulation are low (First nursing action):
• Structured, NON-STIMULATING, uncluttered
• SAFE from physical exhaustion and harm.
□ STAY. Do not leave client alone. Recognize if additional help is needed. Provide physical care if necessary.
□ Establish PERSON-TO-PERSON relationship and maintain an accepting attitude:
• ACCEPT client. Show willingness to LISTEN.
• Encourage, allow EXPRESION OF FEELINGS at clients OWN PACE avoid forcing verbalization.
□ Administer medication as directed and needed. The pharmacology therapy of choice is the ANXIOLYTICS-reduces anxiety so client can
participate in psychotherapy.
□ Assist to cope with anxiety more effectively. Assist to recognize individual strengths realistically
• Encourage measures to reduce anxiety: activities: relaxation techniques, exercises (DANCING, WALKING, JOGGING), hobbies,
talking with support groups, desensitization treatment program
• Provide individual or group therapy to identify anxiety and new ways of dealing with it and develop more effective coping
interpersonal skills.
• If patient can be redirected back to the topic after he gets anxious while the RN gives
discharge teaching, it is an indication that discharge teaching can be resumed.

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PRO Review Soultions and Tutorial Diagnostics
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TYPES OF ANXIETY DISORDER

1. Phobia
2. Obsessive Compulsive
3. Post Traumatic Stress Disorder (PTSD)
4. Generalized Anxiety Disorder (GAD)
5. Panic Disorder

PHOBIA AND PANIC DISORDER

A. Extreme anxiety and apprehension experienced by an individual when confronted with feared object/ situation; commonly begins in early
twenty’s (young adult) as a result of childhood environmental factors characterized by ORDER & RIGIDITY; use compensatory mechanism
of the psychoneurotic pattern of behavior and development of symptoms permits some measure of social adjustment.
B. PRECIPITATING FACTOR: Pressures of decision-making regarding life-style in early adult period
C. TYPES OF PHOBIA
• Agoraphobia: Fear of being alone, fear of open spaces or PUBLIC places where help would not be immediately available (trains,
tunnels, crowds, buses)
A client with agoraphobia who is already able to go outside the house indicates a positive
response to therapy.
Expected outcome for agoraphobia includes going out to see the mailbox
• Social phobia: Fear of public speaking or situations in which public scrutiny may occur
• Simple phobia: Fear of specific objects, animals or situations

D. NURSING IMPLEMENTATION
• Recognize the client’s feelings about phobic object/ situation
Specific precipitants are present with phobia
• Avoid confrontation and humiliation; Provide constant support (Stay with client during an attack) if exposure to phobic object or
situation cannot be avoided
• Do not focus on getting patient to stop being afraid
• Provide relaxation techniques
• Implement behavioral therapy: SYSTEMIC DESENSITIZATION (the #1 treatment for PHOBIA). Administer antidepressants as
ordered

OBSESSIVE-COMPULSIVE DISORDER

A. A psychiatric disorder characterized by persistent, recurring anxiety-provoking thoughts and repetitive acts; Unconscious control of anxiety by
the use of rituals and thoughts
1. OBSESSION: Persistent, repetitive, uncontrollable thoughts
2. COMPULSION: Repetitive, uncontrollable acts of irrational behavior that serve NO rational purpose → rigidity, rituals, inflexibility;
the development of rituals permits some measure of social adjustment
B. ASSESSMENT FINDINGS: Ritualistic, rigid, inflexible; with difficulty making decisions and demonstrates striving at perfection; use verbal
and intellectual defenses
C. NURSING IMPLEMENTATION:
 Provide for physical safety (1st); meet physical needs
 Accept, allow ritualistic activity; DO NOT INTERFERE with it; (The best time to interfere with ritual is after client has
completed it.) Accept behavior but set limits on length and frequency of the ritual. Offer alternative activities; support attempts to
reduce dependency on the ritual; guide decisions
 Provide structured environment, minimize choices
 Provide socialization, group therapy
 Administer CLOMIPRAMINE (ANAFRANIL) as ordered
 A Tricyclic antidepressant used in phobias, anxiety and obsessive-compulsive disorder; SIDE-EFFECTS/ ADVERSE
REACTIONS: Tachycardia, cardiac arrest, dizziness, tremors, seizures, CONTRAINDICATIONS: Pregnancy, hypersensitivity;
Interactions/Incompatibilities: Hypertensive crisis, convulsions, with MAOIs

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POST-TRAUMATIC STRESS SYNDROME

A. A disorder following exposure to extreme traumatic event (wars, rape, natural catastrophes) causing intense fear, recurring distressing
recollections and nightmares

B. ASSESSMENT: 2 Cardinal Sign: FLASHBACK & NIGHTMARES. Images, thoughts, feelings → intense fear and horror, sleep
disturbances.
 Depression, or irritability or outburst of anger
 Exaggerated startle response; Poor impulsive control
 Avoidance; Inability to maintain intimacy; Hypervigilance

C. PRIORITY NURSING DIGNOSIS:


Altered Sleeping Patterns
Altered Skin Integrity
Ineffective Individual Coping

D. NURSING INTERVENTATION
 Encourage VERBALIZATION about painful experience. Show empathy; be non-judgmental; Help feel safe.
 Rational emotive-therapy; Allow to grieve
 Help client identify, label and express feelings safely
 Enhance support systems: Self-help groups, family psychoeducation, and socialization.
In a rape victim, a statement like, “If I should not have worn that red panty, it wont happen to me”,
shows denial

Statement of a rape patient who is beginning to resolve trauma includes, “I’m able to tell my friends
about being raped.”
An RN needs further teaching about caring for a post-traumatic client when she keeps on asking the
client to describe the trauma that caused patient’s distress after recovering from a PTSD.

GENERALIZED ANXIETY DISORDER


A. Description
1. Generalized anxiety disorder is an unrealistic anxiety in which the cause can be
identified.
The two major types of precipitating factors for anxiety are: treats to one biologic integrity and
treats to one’s self-esteem.
Anxiety is one of the defining characteristics of ineffective individual coping.
A patient with anxiety disorder may exhibit difficulty in coping.

2. Physical symptoms occur


B. Assessment
1. Restlessness and inability to relax
2. Episodes of trembling and shakiness
3. Chronic muscular tension
4. Dizziness
5. Inability to concentrate
6. Chronic fatigue and sleep problems
7. Inability to recognize the connection between the anxiety and the physical
symptoms
8. Focus on the physical discomfort

PANIC DISORDER
1. Description
a. The cause usually can not be identified.
b. Panic disorder produces a sudden onset with feeling of intense apprehension
and dread.
c. Severe, recurrent, intermittent anxiety attacks lasting 5 to 30 minutes occur.

2. Assessment
a. Choking sensation
b. Labored breathing
c. Pounding heart
d. Chest pain
e. Dizziness
f. Nausea
g. Blurred vision

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h. Numbness or tingling of the extremities


i. A sense of unreality and helplessness
j. A fear of being trapped
k. A fear of dying
L. Feelings of impending doom
3. Interventions
a. Attend to physical symptoms
b. Assist the client to identify the thoughts that aroused the anxiety and
identify the basis for these thoughts.
c. Assist the client to change unrealistic thoughts to more realistic thoughts.
d. Use cognitive restructuring.
e. Administer anti-anxiety medications as prescribed
A client in panic disorder showing dilated eyes, trembling & says, “I can no longer go further.”
Should
be accompanied in her room & RN should stay w/ her for a while
The goal of intervention in the care of the anxious patient is to enable him to develop his
capacity to tolerate mild
anxiety. A combination of behavioral and somatic approaches is effective in the management of
anxiety.
Therapeutic communication appropriate to patient showing signs of panic disorder
includes providing a concrete direction

ANXIOLYTICS/ANTI-ANXIETY
Another word: Sedatives/Hypnotics/Minor Tranquilizer

For: Delirium, anti-anxiety, insomnia


ACTION: Increases GABA (gamma amino butyric acid)
USES: Major use to reduce anxiety; also induce sedation, relax muscles, inhibit convulsion; Used in neuroses, psychosomatic disorders,
functional psychiatric disorders. DO NOT modify psychotic behavior.
Most commonly prescribed drugs in medicine
Greatest harm: When combined with ALCOHOL

I. Benzodiazepine Code: -ZEPAM/ZOLAM


Action: Anticonvulsant, muscle relaxant & anxiolytic

Diazepam (Valium)* best for: Status epilepticus , the best for delirium
tremens (alcohol & cocaine withdrawal)
Estazolam (Prosom)
Alprazolam (Xanax)
Chlorazepate (Tranxene)
Oxazepam (Serax)* the best in sundown syndrome (seen in Alzheimers)
Advantage: Not hepatotoxic
Lorazepam (Ativan)* 2nd drug for sundown syndrome
Triazolam (Halcion)* Anti-insomnia
Temazepam (Restoril)* Anti-insomnia
Flurazepam (Dalmane)* Anti-insomnia; do not stop abruptly  because
of rebound grand mal seizure
Midazolam (Dormicum)
Prazepam (Centrax)
Chlordiazepoxide (Librium)* 2nd drug of choice for delirium tremens
Clonazepam (Klonopin)
Halazepam (Paxipam)

Side Effects: #1 Vital sign to be monitored: Respiratory Rate due to its


Lethal Side Effect; Respiratory Depression
1. Early  decrease LOC  Lethargic
Late/Fatal  decrease RR  Respiratory Depression  RR below 12
Avoid strenuous activities

Antidote for Benzodiazepine intoxication: FLUMAZENIL (ROMAZICON); an anxiolytic antagonist

II. Barbiturates
Action: Used as an anticonvulsant besides being a sedative

Code: TAL / AL

Secobarbital (seconal)
Phenobarbital (luminal)* commonly used anticonvulsant barbiturate

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PRO Review Soultions and Tutorial Diagnostics
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Methohexital (Brevital)
Amobarbital (Amital)

III Atypical Anxiolytics

Meprobamate (Equanil, Milltown)


Chloral Hydrate (Noctec)
Hydroxyzine (Atarax, Iterax, Vistaril)* anti emetic & antihistamine
Diphenhydramine (Benadryl)* Antiparkinsons, Antihistamine,
Anxiolytic (addictive)
Zolpidem (Ambien, Stillnox) sleeping aid

1. SIDE EFFECTS
 DROWSINESS (Do not drive; assistance w/ walking; NO alcohol)
 Mental confusion (Evaluate mood, sensorium, affect)
 Habituation and increased tolerance
 Withdrawal symptoms: high doses & prolonged use (>6mo)

PSYCHOTIC DISORDER: SCHIZOPHRENIA

Definition: Severe impairment of mental & social functioning with grossly impaired reality testing, sensory perception and with deterioration &
regression of psychosocial functioning.

A. ASSESSMENT FINDINGS (GENERAL SIGNS)

THE FOUR A’s of SCHIZOPHRENIA ACCORDING TO BLEULER

A ASSOCIATIONS, LOOSE: Jumping to different topics WITHOUT association or relevance


AMBIVALENCE (Two opposing feelings toward others at the same time)
AUTISM (withdrawal from environment and others) → magical thinking, neologism, aloofness)

AFFECT, FLAT (Inappropriate or no display of feelings)


#1 HALLUCINATION of Schizophrenia is Auditory.

THEORIES:
1. Increased dopamine –coming from the substancia nigra
2. Trauma  PTSD
3. Double-bind theory  2 kinds of information/communication
4. Genetics 65% chances- if two parents are diagnose with schizophrenia
32.5% chances- if 1 parent is diagnosed with schizophrenia
5. Drug addicts and alcoholics: High probability for schizophrenia due to increase
Delusions & hallucination

DSM V Criteria for Schizophrenia:

Characterized by both (-) & (+) symptoms & social / occupational dysfunction for at least SIX (6) months.
Patient with 5 admissions in 2 yrs is considered a chronic schizo.

(+) POSITIVE SIGNS OF SCHIZOPHRENIA: Due to EXCESS DOPAMINE

Do you know HILDDA PI?

Hallucination, Illusion, Looseness of Association, Delusion, Disorientation & Agitation


Paranoia & Insomnia

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PRO Review Soultions and Tutorial Diagnostics
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Schizophrenic patient says, “Pretty red dress, tomatoes are red…” is showing looseness of
association

(-) NEGATIVE SIGNS OF SCHIZOPHRENIA: Due to LACK OF DOPAMINE

Remember your POOR A’s?


Poor judgment, Poor insight, Poor self care
Alogia, Anergia, Anhedonia

NURSING DIAGNOSIS FOR NEGATIVE SYMPTOMS OF SCHIZOPHRENIA:


1. Alteration in Thought Process; 2. Alteration in Content of Thought

OTHER NEGATIVE SYMPTOMS:

All this signs & symptoms can also be seen in SAM (Schizophrenia, Alzheimer’s & Manic)

1. Neologism (creating NEW WORDS) vs. Word Salad (incoherent mixture of words)
2. Flight of Ideas (jumping from one RELATED topic to another): Commonly seen in MANIC
patients, also in Schizophrenia.
3. Verbigeration (meaningless repetition of action words (Verb)) vs. Perseveration
e.g. 1st stimulus  correct response
2nd & following stimulus  still responding to the 1st stimuli
4. Circumstantiality (beating around the bush; answers but delayed) vs. Tangentiality (did not answer the
stimulus/ question)
5. Clang association (use of rhymes in sentences) vs. Echolalia/Parroting & Echopraxia
(Commonly seen in AUTISM)

B. PRIORITIZED NURSING DIAGNOSES FOR ALL TYPES OF SCHIZOPHRENIA:


1. Risk for violence: Directed toward self or other (priority!!!)
2. Self-care deficit
3. Thought process, altered
4. Sensory/perceptual alterations ( related to illusion, delusion & hallucination)
5. Social isolation

C. 5 (FIVE) TYPES OF SCHIZOPHRENIA:

1. PARANOID: Presenting sign is


SUSPICIOUSNESS, ideas of persecution and delusions; sees environment as hostile and threatening. REMEMBER the 4 P’s:
Projection (#1 defense mechanism), Proxemics( 7 feet away from the patient), Passive Friendliness (#1 attitude therapy: No touching, ,
no whispering & laughing) , delusion of Persecution (#1 delusion of Paranoid Schizophrenia) ,
A patient who says,” The other staff members are laughing at my back.” shows a paranoid
delusion of schizophrenia.
Schizophrenic says, “Someone has placed a transistor in my brain,” correct interpretation shows
paranoid delusion
Statement like, “I don’t like to eat meat because animal produced foods are
Poisonous”, shows suspicious paranoid type schizophrenia.

Developmental Stage FIXATION: ORAL PHASE (TRUST vs. MISTRUST)

NURSING CONSIDERATION:
1. Consistency to build trust
2. Food: PACKED OR SEALED foods except canned goods: No metal
3. Social Isolation – no group session when schizophrenic
Paranoid who is suspicious saying, “This place is meant for bugs & prison,” In order to
encourage trust, the patient should be involved in the plan of care.

2. CATATONIC: With stereotyped position (catatonia) with waxy flexibility, mutism, bizarre mannerism.
#1 Defense mechanism: Autism & mutism
#1 Cardinal Sign of Catatonia – waxy flexibility (cerea flexibilitas)

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 20


PRO Review Soultions and Tutorial Diagnostics
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-Similar in children with autism


- Most dangerous/serious type of schizophrenia– may die from dehydration

CATATONIC CHARACTERISTICS:
- Catatonic stupor – markedly slowed movement.
- Catatonic posturing- bizarre or weird positions
- Catatonic rigidity – cementation/stone-like position
- Catatonic negativism – resistance towards flexion & extension
- Catatonic hyperactivity or excitability:

PRIORITIZED NURSING DIAGNOSIS:


1. Fluid & Electrolyte Imbalance
2. Altered Nutrition less than body requirement
3. Self Care Deficit

3. DISORGANIZED: Another word is Hebephrenic. Characterized with inappropriate behavior: Silly crying, laughing, regression,
transient hallucinations (Auditory).
All behaviors are similar with toddlers since they are anal fixated.
Developmental Stage FIXATION: Anal Fixation
#1 Defense Mechanism: Regression & Fixation

4. UNDIFFERENTIATED or MIXED : Symptoms of more than one type of schizophrenia


- has delusions & disorganized behavior but DOES NOT meet the criteria for the above
sub types alone. The #1 drug of choice is Fluphenazine (Prolixin decanoate)

5. RESIDUAL: No longer exhibits overt symptoms, no more delusions but still has negative symptoms or odd beliefs or unusual
perceptions.
Undifferentiated type chronic schizophrenia must be referred to a program promoting
social skills due to functional loss deficit.

D. PRINCIPLES OF CARE
1. Maintenance of safety: Protect from altered thought processes. Respond to feelings, and not to delusions; Do not argue; Validate
reality; remove from areas of tension
Suspiciousness & paranoid patient is threatening to the staff, the action of an RN that
shows a need for further teaching is when shegoes to the room of a pt. who yells,
“Everyone, out of here,”
Appropriate action of RN to a Schizophrenic who yells loudly, talks to wall and saying
“Don’t talk to me, bastard.” includes walking towards the pt & ask him who he is talking to.
2. Meeting of physical needs: May have to be fed / bathe initially
3. Establishment and maintenance of therapeutic relationship: Engage in individual therapy; Promote trust; Encourage expression by
verbalizing the observed; Offer presence-Tolerate long silences
4. Implementation of appropriate family, group, social or diversional therapies
Patients with schizophrenia need activities that do not require interaction, so solitary activities are
preferred over team activities.

Admission assessment of a Schizophrenic client reveals auditory hallucination, and drinking more
than 6 L of water daily for past weeks, priority focus should be hyponatremia.
Desired efficacy of treatment in schizophrenic patient who is mute & immobilized includes standing
up when RN enters the room.

ANTIPSYCHOTICS

Another word: Neuroleptic / Major Tranquilizers

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 21


PRO Review Soultions and Tutorial Diagnostics
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USES: Schizophrenia, acute mania, depression and organic conditions; Non-psychiatric cases: Nausea and vomiting, pre-anesthesia,
intractable hiccups.
Antipsychotics can only decrease the positive symptoms of schizophrenia, but not the negative
symptom such as ambivalence.

Action: ↓ delusion, hallucinations, looseness of association


to decrease levels of dopamine in the substantia nigra

I. Phenothiazine Code: AZINE


Fluphenazine (Prolixin)*
Acetophenazine (Tindal)
Pherphenazine (Trilafon)
Promazine (Sparine)
Chlorpromazine (Thorazine)*#1 that causes photosensitivity/photophobia;
Side effects: Causes also red orange urine
In liquid form is usually put in a chaser  Chaser: 60- 100 ml juice (prone or tomato); to prevent
constipation & contact dermatitis; taken with straw (bite straw & sip)

Mesoridazine (Serentil)
Thioridazine (Mellaril)* ceiling dose/day: 800 mg  Adverse Effect: Retinitis pigmentosa
Prochlorperazine (Compazine)* #1 commonly used anti emetic
Compazine causes anticholinergic side effects
Trifluoperazine (Stelazine)

II. Butyrophenones Code: PERIDOL


Haloperidol (Haldol, Serenase)* #1 drug used for extreme violent behavior
Instruct patient taking Haldol to wear sunscreen
Droperidol (Inapsine)

III. Thioxanthenes Code: THIXENE

Chlorprothixene (Taractan
Thiothixene (Navane)

IV. Atypical Antipsychotics Code: DONE / ZAPINE or APINE

Olanzapine (Zyprexia)
Clozapine (Clozaril) #1 that causes Agranulocytosis & Blood Dyscrasia
“I will need to monitor my blood level to continue my medication.” shows a correct
understanding of a patient while taking Clozaril.
Loxapine (Loxitane)
Risperidone (Risperidone) #1 drug for Korsakoff’s psychosis
Molindone (Moban)

Aripiprazole (Abilify) newest antipsychotic drug

SIX COMMON ANTICHOLINERGIC SIDE EFFECTS OF ANTIPSYCHOTICS

(Anticholinergic effects are drug actions of antipsychotic drugs because they BLOCK MUSCARINIC CHOLINERGIC
RECEPTORS)

CODE: BUCO PanDan – anticholinergic S/Es

1. Blurring of Vision - ↑ sympathetic reaction (don’t operate machinery);


Mydriatic – pupil dilate  sympa  ↑ IOP  don’t use in glaucoma

2. Urinary Retention – (Post Partum, Autonomic Dysreflexia, paraplegia)


Nursing Interventions:
1. Provide Privacy – give bed pan

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 22


PRO Review Soultions and Tutorial Diagnostics
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2. Sounds of dripping water – faucet


3. Intermittent cold & warm compress

3. Constipation
Nursing Interventions:
1. Prevent constipation ↑ fiber (residue) AG or roughage,
prune/pineapple/papaya juice/ fruits
2. ↑ OFI
3. ↑exercise

4. Orthostatic Hypotension/Postural Hypotension


- take BP in supine, Fowler’s & standing position. Difference of BP 15-20 mm Hg below
S/Sx: Pallor, dizziness
Nursing consideration: Slowly change position
Told patient to dangle feet first before standing

5. Pan Photosensitivity (photophobia)


Nursing Intervention:
1. Use sun glasses, sun block, long sleeves or/and umbrella
Patients taking antipsychotic should be instructed to wear wide brimmed hat when
going outside

6. Dan Dry mouth/ Xerostomia


Prioritized Nursing Intervention:
Give (1) ice chips, (2) chewing gum, (3) sips of water

ACUTE/COMMON SIDE-EFFECTS FOR PROLONGED USED OF ANTIPSYCOTICS

Extrapyramidal Symptoms (EPS) Common Signs & Symptoms:

Definition of EPS: Reversible side effect (except TARDIVE DYSKINESIA), which is a result of neurological dysfunction of the
Extrapyramidal System.
Patients taking with prolonged antipsychotic medications should always be assessed for symptoms of
extrapyramidal symptoms.

1. Akathisia –another word: Motor restlessness  1-6 wks


Signs of motor restless: Foot tapping, finger fidgeting, can’t sit down for more than 15 minutes and pacing back &
forth.
Patient is unable to remain still
Drug of Choice: CODE: CBA

#1 Cogentin (Benztropine Mesylate)


#2 Benadryl (Diphenhydramine Hcl)
#3 Akineton (Biperiden Hcl)

2. Dystonia – #1 cardinal Sign: Oculogyric crisis = involuntary rolling of eyeballs, neck shoulder, jaw and throat spasm (dysphagia)  2-
5 days
Drug of Choice: CODE: CBA

#1 Cogentin (Benztropine Mesylate)


#2 Benadryl (Diphenhydramine Hcl)
#3 Akineton (Biperiden Hcl)

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 23


PRO Review Soultions and Tutorial Diagnostics
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3. Pseudoparkinsonism - another word: Drug-induced Parkinsonism – #1 sign: Pill-rolling tremors. Other signs: Mask-like face, flat
affect, shuffling gait or festinating gait, cogwheel rigidity.
DRUG OF CHOICE:
#1 Artane (trihexyphenydyl)
#2 Amantadine ( Symmetrel) can also be used in Chicken pox, also an ANTI VIRAL

4. Tardive Dyskinesia – Starts with T: TONGUE (tongue rolling & tongue protrusion) lip smacking, tongue rolling, protrusion of the tongue,
vermicular or vermiform tongue rolling  irreversible. This is an EMERGENCY!!!
Symptoms of tardive dyskinesia include fly catcher’s mouth, tongue thrusting, facial
grimacing, puckering of cheeks, and drooling of saliva.
--administer Artane, Benadryl, Cogentin, Antiparkinsonian drug

5. Akinesia – absence of kinetic movements

ANTI- EPS MEDICATION

CODE: PACABBA
- Usually they are anticholinergic & antiparkinsonian drugs

Procyclidine (kemadryl, kemadrin)


Artane ( trihexyphenydyl)
Cogentin (Benztropine mesylate)
Akineton (biperiden Hcl)
Bromocriptine (Parlodel)
Benadryl (Diphenhydramine)
Amantadine (Symmetrel)

ADVERSE EFFECT OF ANTIPSYCHOTIC DRUGS:

Neuroleptic Malignant Syndrome RARE, LIFE-THREATENING : (EXTREME EMERGENCY): #1 Cardinal Sign is High fever,
tremors, tachycardia, tachypnea, sweating, hyperkalemia, stupor, incontinence, renal failure, muscle rigidity (Discontinue all drugs
STAT; ventilation; hydration; nutrition; renal dialysis; hydrotherapeutic measures). Elevated blood pressure and
diaphoresis are indicative of Neuroleptic malignant syndrome, which is a medical emergency.
ANTIDOTE: Dantrolene (Dantrium) or Bromocriptine (Parlodel)
Bromocriptine is both an Antiparkinsons & Anti prolactin

AFFECTIVE / MOOD DISORDERS

MODELS OF CAUSATION: Genetic; Aggression turned inward; Objects loss; Personality disorganization; Cognitive:
Hopelessness; Learned helplessness- hopelessness; Behavioral: Loss of positive reinforcement; Biological: Decreased serotonin and
norepinephrine *; Life stressors; and Integrative: chemical, experiential, behavioral variables

DEPRESSION: An abnormal extension or over elaboration of sadness and grief; oldest and most frequently described psychiatric
illness; a pathologic grief reaction experienced by an individual who does not mourn
• The term depression is used in varied ways: a sign, symptom, syndrome, emotional state, reaction, disease or clinical entity.
• May be mild, moderate, severe, with (uncommon) or without psychotic features

I. TYPES: Depressive Disorders, Manic-Depressive (Bipolar) Disorders, Suicidal Behavior

A. DEPRESSIVE DISORDERS: Depressive episode with no manic episodes


1. Major depression, single episode
2. Major depression, recurrent: Repeated episodes of major sadness or depression separated by long intervals, occurring in
clusters or increasing with age*
3. Dysthymia: Chronic depressive mood problems occurring in the absence of a major depressive or organic or psychotic diagnosis.

DIFFERENTIATION/CATEGORY:
Moderate Depression – crying at night
- Dysthymia – painful depression for 2 years

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 24


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

*Severe Depression – Crying at early morning, depression less than 2weeks


*Major Depression – Severe depression for more than 2 weeks
* - both of them have the same characteristics

• BEHAVIORS COMMONLY ASSOCIATED WITH DEPRESSION


a. Affective: Anger, anxiety, apathy, bitterness, hopelessness, helplessness, sense of worthlessness, low self-esteem, denial of
feelings
b. Physiological: Fatigue, backache, anorexia, vomiting, headache, dizziness, insomnia, chest pain, constipation, weight
change, abdominal pains*
c. Cognitive: Confusion, indecisiveness, ambivalence, inability to concentrate, pessimism, loss of interest, self-blame
d. Behavioral: Altered activity level, over-dependency, psychomotor retardation, withdrawal, poor hygiene, agitation, irritability,
tearfulness
In a depressed patient, hostility is turned towards the self, while in manic patient,
hostility is turned
towards the environment.
Depression in children results to anhedonia (energy loss & fatigue, decreased interest in
previously enjoyed activities) like playing alone during recess.

• DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION: At least five of the following, most of the day, nearly daily, for 2 weeks:
1. Early morning depression 6. Feelings of worthlessness &
2. Loss of interest or pleasure ambivalence (fear of death vs. fear living) *
(ANHEDONIA)* 7. Self care deficit*
3. Insomnia* 8. History of suicide*
4. Psychomotor retardation (slow mov’t) 9. Weight loss or gain
5. Fatigue or loss of energy (anemia) 10. Flat affect*
11. Constipation*

PREDISPOSING FACTORS:
1. Single, Annulled & Divorced
2. Loss of loved one (situational crisis)
3. SAD – Seasonal Affective Disorder – common on winter season (Nov.-Feb.) or intimate months
Seasonal depression occurs during winter and fall this is due to abnormal melatonin
metabolism.
Intervention for pt with seasonal affective disorder (SAD) during a depressed mood
includes the use of broad spectrum light in high activity area. This produces high
intensity color like broad day light.
Also instruct the pt that the light source must be 3 ft away from the eye
4. Caucasians/Afro-Americans/Asians*
5. Alcoholics/Drug addicts*
A 66 y/o American men, no hobby, no friend, retired 6 yrs ago, no money & has history of
alcohol abuse is at risk for suicide
6. Protestants
7. Incurable Illness*
8. Post partum depression
9. Schizophrenia*

Prone: Male Age bracket prone for suicide


#1. Adolescent (identity crisis)
2. Elderly (ego-despair)
3. Middle age men (45 y.o. above)
4. Post partum depression (7 days/2-4 weeks)

Suicide and Self-destructive Behavior

Suicide is never a random act. Whether committed impulsively or after painstaking consideration the act has both a message and a purpose. In
general the purpose or reason for suicide is to escape; to get away or end an intolerable situation, crisis, difficulty, or relationship, e.g., escaping a
terminal illness, avoiding being a burden to others, resolving an untenable family situation, or to avoid punishment or exposure of socially or
personally unacceptable behavior.

Self-destructive behavior is action by which people emotionally, socially and physically damage or end their lives. Typical behavior are biting one’s
nails, pulling one’s hair scratching or cutting one’s wrist. A complete suicide is the most violent self-destructive behavior.

Levels of self-destructive behavior:

1. Chronic self-destructive behavior – e.g. smoking, gambling, self-mutilation

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 25


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

2. Suicidal threat – a threat more serious than a casual statement of suicidal intent and accompanied by behavioral changes, e.g., mood
swings, temper outbursts, decline in school or work performance
3. Suicidal gesture – more serious warning signal than a threat that maybe followed a suicidal act that is carefully planned to attract
attention without seriously injuring the subject
4. Suicidal attempt – a strong and desperate call for help involving a definite risk.

Cognitive styles of suicidal patients:

1. Ambivalence. They have 2 conflicting desires at the same time: To live and to die. Ambivalence accounts for the fact that a suicidal
person often takes lethal or near-lethal action but leaves open the possibility for rescue.
2. Communication. Some, people cannot express their needs or feelings to others, or when they do, they do not obtain the results they hope
for. For them, suicide becomes a clear and direct, if violent, form of communication.

Demographic Variables – suicide rates are higher among the following:

1. Single people
2. Divorced, separated or widowed
3. People who are confused about their sexual orientation
4. People who have experienced a recent loss: divorce, loss of job, loss of prestige, loss of social status or who are facing the threat of
criminal exposure
5. Caucasians, Eskimos and Native Americans
6. Protestants or those who profess no religious affiliation

Clinical variables:

1. People who have attempted suicide before


2. People who have experienced the loss of an important person at some time in the past or the loss of both parents early in life, or the loss of
or threat of their spouse, job, money or social position
3. People who are depressed or recovering from depression or a psychotic episode
4. Those with physical illness, particularly when the illness involves an alteration of body images or lifestyle
5. Those who abuse alcohol or drugs
6. Those who are recovering from a thought disorder combined with depressed mood and / or suicidal ideation ( hallucinations that tell
them to kill or harm themselves)

Management – people bent on suicide almost always give either verbal or nonverbal clues of their intent. They actually make a powerful attempt to
communicate to others their hurt ad desperation. They are crying out for help.

1. A lethality assessment scale (Table 2) is an attempt to predict the likelihood of suicide.

Table 2: Lethality Assessment Scale

Key to Scale Danger to Self Typical Indicators

1 No predictable risk of immediate Has no notion of suicide or history of


suicide attempts, has satisfactorily social
support network, and is in close
contact with significant others

Person has considered suicide with


low lethal method; no history of
2 Low risk of immediate suicide attempts or recent serious loss; has
satisfactorily support network; no
alcohol problems; basically wants to
live

Has considered suicide with high


lethal method but no specific plan or
threats; or has plan with low lethal
Moderate risk of immediate method , history of low lethal
3 suicide attempts, with dysfunctional family
history and reliance on Valium or
other drugs for stress relief; is

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PRO Review Soultions and Tutorial Diagnostics
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weighing the odds between life and


death

Has current high lethal plan,


obtainable means, history of previous
attempts, has a close friend but is
unable to communicate with him or
her a drinking problem; is depressed
and wants to die

High risk of immediate suicide Has current high lethal plan with
4 available means, history of high lethal
suicide attempts, is cut off from
resources; is depressed and uses
alcohol to excess, and is threatened
with a serious loss, such as
unemployment or divorce or failure in
school age more in elderly and
adolescents
Very high risk of immediate
suicide
5

General guidelines – the general task of the nurse is to work with the client to stop the constricted processing of suicidal thinking long enough
to allow the client and the family to consider alternatives to suicide.

a. Take only threat seriously


b. Talk about suicide openly and directly
c. Implement basic suicide precautions:

• Check on the client at least every 15 minutes or require the client to remain in public places
• Stay with the client while all medications are taken
• Search the client’s belongings for potentially harmful objects. Make the search in the client’s presence and ask
for the client’s assistance while doing so
• Check articles brought in by visitors
• Allow the client to have regular food tray but check whether the glass or any utensils are missing when
collecting the tray
• Allow visitors and telephone calls unless the client wishes otherwise
• Check that visitors do not potentially dangerous objects in the room

d. In addition to the above, maximum suicide precautions mean:

• Provide one-to-one nursing supervision. The nurse must be in the room with the client at all times
• Maintain the client’s safety in the least restrictive manner possible
• Do not allow the client to leave the unit for test or procedures
• Serve the client’s meals in an isolation tray that contains no glass or metal silverware

e. Expect that the client will be experiencing shame, and work to assists the client toward self- acceptance
f. Relieve the client’s obvious immediate distress
g. Find out what, in the client’s view, the most pressing need is
h. Assume a nonjudgmental, caring attitude that does not engender self-pity in the client
i. Ask why the client chose to attempt suicide at this particular moment. The answer will shed light on the meaning suicide has
for this patient and may provide information that can lead to other helpful interventions
j. Decide if a no-harm, no suicide contract will be used
k. Be careful not to encourage staff behaviors that give clients or staff members a false sense of security
l. Do not make unrealistic promises
m. Encouraged the client to continue daily activities and self-care as much as possible
n. Decide with the client which family members and friends are to be contact and by whom
o. Be prepared to deal with family members who may be confused, angry or uninterested
p. Evaluate the client’s need for medication
q. Evaluate the plan developed in collaboration with the client and arrange for appropriate follow-up

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 27


PRO Review Soultions and Tutorial Diagnostics
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r. Monitor your personal feelings about the client and decide how they may be influencing your clinical work
s. Work with other team members to evaluate the issues fully
t. Do a body examination
u. Recognize that people can and have hanged or strangled themselves with shoelaces, brassiere straps, pantyhose, robe belts,
etc.

2 LETHAL METHODS OF SUICIDE:


1. Low-risk = slashing of the radial pulse (more o females)
2. High-risk = drowning, gun shot, hanging, jumping from a very high
place/building, overdose of tranquilizer (Midazolam & Dormicum)

SUICIDAL BEHAVIORS:

SUICIDAL GESTURE: Directed toward the goal of receiving attention rather than actual self-destruction; b) SUICIDAL THREAT:
Occurs before the overt suicidal activity takes place: “Will you remember me when I am gone,” “Take care of my children”; c)
SUICIDAL ATTEMPTS: Any self-directed actions taken by the individual that will lead to death if not interrupted. A most suicidal
person has made a specific plan, and has the means readily available.
Best question to be asked after a patient who recovers from an overdose of pills includes
asking “Do you still want to end your life?”

IMPENDING SIGNS OF SUICIDE:

1. Sudden elevation of mood/sudden mood swings*


When a depressed patient suddenly becomes cheerful, it means that the patient is
recovering
from depression and is in danger of committing suicide.
2. Giving away of prized possessions*
3. Delusion of Omnipotence (divine powers)
Used by SS (Suicidal, Schizophrenia)
4. When the patient verbalizes that the 2nd Gen TCA is working.
less than 2-4 wks ( telling a lie)

• Suicidal attempts are common when client is strong enough to carry out a suicidal plan, usually 10-14 days after start of
medication, and after ECT

USUAL TIME FOR SUICIDE:


1. Early in the morning RATIONALE: The depression at this time is HIGH
2. In between nursing shifts RATIONALE: Nurses at this time are very busy

NURSING DIAGNOSIS: (common) Risk/Potential for Injury Directed to Self

STEP BY STEP PRIORITIZE NURSING INTERVENTIONS:

1. One-on-one nursing monitoring/intervention (never leave the client)*


2. Do not leave the patient for the 1st 24 hrs. (No suicide contract)*
3. Offering of self (best therapeutic communication)*
4. No metallic objects
5. No sharp objects
6. Needs stimulus – bright room Rationale: to see suicidal acts
7. Avoid religious music (increases guilt) and love songs = non-suggestive song is needed
8. Check for impending signs of suicide = sudden elevation of mood;
#1 – sudden mood swings
A female patient who becomes euphoric for no apparent reason shows a behavior that indicates
recovery
from depression, which increases the risk for suicide.
9. Activities focus on self-care
10. Join group therapy
Depressed patients usually turn their hostile feelings towards themselves. Providing an activity
that serves as an outlet for these aggressive feelings will make the patient feel less guilty.
During family therapy, a mother asks, “How long will my daughters have suicidal thoughts?”
appropriate response of the RN- ‘’ Your daughter will go on to view suicide as a way of
coping.”
11. Monitor in giving medication – do not leave patient after giving medication for 30 minutes. Check under the tongue & pillow
12. Monitor patient in CR, between shift & during endorsement
13. #1 Attitude Therapy: Kind Firmness
14. Step by step Tx: ANTIDEPRESSANT another word is THYMOLEPTICS

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 28


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

1st SSRI (Selective Serotonin Reuptake Inhibitor) A


2nd Second Gen. TCA
3rd MAOI
4th ECT (last resort)
15. Meet physical needs:
Promote eating, rest, elimination
Promote self-care whenever appropriate / possible
16. Support self-esteem:
Warm and consistent care
Being patient with client’s slowness
Simple tasks that increase success and self-esteem and imply confidence in capabilities
Example: Self care activities that will not easily tire the patient. Rationale: Depressed patients have fatigue.
17. Decrease social withdrawal: Sit with client during quiet times; introduce to others when ready
The priority focus for a suicidal patient in the ER with a slash in her wrist is her physiologic
homeostasis.
Assess attempt for suicide in a 16 y/o girl who is eating & sleeping poorly since break-up
and saying,” My life is ruined now.”

ANTIDEPRESSANTS or THYMOLEPTICS

I. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

Usually the FIRST LINE of drug. RATIONALE: FEWER SIDE EFFECTS


Action: Balance Serotonin – gradual effect (usually 2 weeks)
Effect: 2 wks.
Code: XETINE/ODONE

Fluoxetine HCl (Prozac) – dry mouth (xerostomia)


Paroxetine HCl (Paxil)
Trazodone (Desyrel)) – adverse effect: Priapism (prolonged use)
Nefazodone (Serzone)
Fluvoxamine (Luvox)
Sertraline (Zoloft) – causes GI upset (diarrhea, insomnia): always with meals
Venlafaxine (Effexor)
Citalopram (Celexia)

Common Side Effects:


1. Weight Loss
2. Insomnia (single am dose)

Nursing Considerations:
1. For insomnia:
a. Induce sleep thru: 1. Warm bath (systemic effect)
2. Warm milk/banana (active substance: tryptophan)
3. Massage
b. Give meds in single AM dose
Antidepressants are best taken after meals

II. SECOND GENERATION TRICYCLIC ANTI DEPRESSANT

Action: Increases norepinephrine and/or serotonin levels in CNS by blocking their uptake by presynaptic neurons or it balances
Serotonin & Epinephrine levels.

Effect: 2-4 wks.


Code: PRAMINE/TRYPTILLINE

Clomipramine HCl (Anaframil) #1 for OCD*


Imipramine (Tofranil)* the best drug for enuresis
Amitryptilline (Elavil)
Protryphilline (Vivactil)
Maprotilline (Ludiomil)
Norpramine (Desipramine) #1 antidepressant for elderly depression.
RATIONALE: Fewer anticholinergic S/E
Nortryptilline (Pamelor, Aventyl)
Trimipramine ( Surmontil)
Buproprion (Wellbutrin) 400 mg/day*(ceiling dose) EXCESS INTAKE:
Grand mal seizure
Doxepine (Sinequan)

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 29


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

Amoxapine (Asendin)

Common Side Effects: 1. Sedation (at night)


2. Weight gain

Nursing Consideration: 1. Give meds at night

# 1 adverse effect – cardiac dysrhythmias


#1 screening test before taking TCA – ECG
When a depressed client taking TCA shows no improvement in the symptoms, the nurse must anticipate
the physician to discontinue TCA after two weeks and start on Parnate.
Nursing intervention before giving the drug includes checking the BP.

III. MAOI – MONO AMINE OXIDESE INHIBITOR


ACTION: Psychomotor stimulator or psychic energizers; block oxidative deamination of naturally occurring monoamines
(epinephrine, NOREPINEPHRINE, serotonin) → CNS stimulation

Effect: 2 weeks

CODE: PAMMANA
Parnate (tranylcypromine)
Marplan (Isocarboxacid)
Mannerix (Moclobemide) *the newest MAOI
Nardil (Phenelzine SO4)

CONTAINDICATIONS: TYRAMINE + MAOI = HYPERTENSIVE CRISIS


1. Tyramine rich-food, high in Na & cholesterol  Hypertensive Crisis
1. Aged cheese (except cottage cheese, cream cheese),
Cheddar cheese and Swiss cheese are high in tyramine and should be
avoided.
2. Canned foods such as sardines, soy sauce & catsup
3. Organ meats (chicken gizzard & liver) & Process foods
(salami/bacon) ↑ Na
3. Red wine (alcohol)
4. Soy sauce
5. Cheese burger
6. Banana, papaya, avocado, raisins (all over ripe fruits except apricot)
7. Yogurt, sour cream, margarine;
8. Mayonnaise
9. OTC decongestants
10. Pickled foods, Pickled herring
Foods contraindicated in MAOI therapy includes figs, bologna, chicken liver, meat tenderizer, ,
sausage, chocolate, licorice, yeast, sauerkrauts, Food safe to give includes fresh fish, Cream, Yogurt,
Coffee, Chocolate , Italian green beans, sausage, yeast,

Antidote: CALCIUM CHANNEL BLOCKERS (-DIPINE)


1. Verapamil (Calan)
2. Phentolamine (Regitine)  also the #1drug for Pheochromocytoma (tumor in
the medulla)

IV. ELECTROCONVULSIVE THERAPY (ECT)

ECT is passing of an electric current through electrodes applied to one or both temples to artificially induce a grand mal seizure for the safe and
effective treatment of depression.
ECT’s mechanism of action is unclear at present

Advantages: Quicker effects than antidepressants; Safer for elderly; 80 % improvement rate of major depressive episode with vegetative aspects

- Best therapy for major depression (last resort)


- Invasive
- Induction of 70-150 volts of electricity in).5-2secs. Then, it is followed by a grand-mal seizure lasting 30-60 secs.
- 6-12 treatments, “every other day”

- Before ECT a major depressed client undergo the ff meds:


1. SSRi (Selective Serotonin Reuptake Inhibitor inhibitor) –2 wks

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 30


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

2. Antidepressants  TCA 2nd Generation – 2-4 wks


3. MAOi – 2 wks
4. ECT (last resort)

Side Effects:
1. Temporary RECENT Memory Loss –
ANTEROGRADE amnesia
Intervention: Re-orient client to 3 spheres
2. confusion/disorientation – (usually 24 hours)
3. Headache  ↑ 02 demand, ↑ cerebral hypoxia
4. Muscle spasm
5. Wt. gain (stimulate thalamic/limbic  appetite)

Contraindicated:

1. PPPP – Post MI, Post CVA, pacemaker, pregnant women


2. Neurologic problem  Alzheimer’s, degenerative disorder
3. Brain tumor, weakness of lumbosacral spine

A. Legal/Pre-Nursing Responsibilities: Preparation: Similar to preparing a client for surgery:

1. Informed Consent – if client is coherent, if not a guardian may sign the consent forms.
2. No metallic objects
3. No nail polish to check peripheral circulation
4. No contact lenses it may adhere to the cornea
5. Wash & dry hair

6. Give following medications BEFORE ECT:


a. Atropine sulfate – anticholinergic
PRIMARY purpose – to dry secretions and prevent aspiration
SECONDARY purpose – to prevent bradycardia (vagolytic)
b. Phenobarbital (Luminal), Methohexital (barbiturate Na) -
minor tranquilizer also an anticonvulsant
c. Succinylcholine (Anectine) – muscle relaxant
7. Priority vs. to focus ABC; check RR 12 less; LOC
8. Before ECT  supine position; after ECT  side-lying
9. Have patient VOID before giving ECT

Nursing Diagnosis:
1. Risk for Airway Obstruction/aspiration
2. Risk for Injury
3. Impaired/Altered Cognition/LOC

Nursing Intervention

5 S in Seizure 1. Safety (#1 objective)


2. Side-lying (#1 Position)
3. Side rails up
4. Stimulus ↓ (no noise & bright lights)
5. Support the head with a pillow AFTER the seizure

 FIRST & TOP priority: Ensure a patent airway. Side-lying after removal of airway. Observe for respiratory problems
 Remain with client until alert. VS q 5 min until stable.
 REORIENT: Time, place (unit), person (nurse); Reassure regarding confusion and memory loss. Same RN before & after.

B. BIPOLAR DISORDERS: With one or more manic episodes, with or without a major depressive episode

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 31


PRO Review Soultions and Tutorial Diagnostics
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1. Bipolar, depressive: Most recent or current behavior displaying major depression


2. Bipolar, manic: Most recent or current behavior displaying overactive, agitated behavior
3. Bipolar, mixed: Rapid intermingling of depressed and manic behavior
4. Cyclothymania: Numerous occurrences of abnormally depressed moods over a period of at least 2 years
5.
• MANIA: Mood that is elevated, expansive, or irritable
Manic behavior is a defense against depression since the individual attempts to deny feelings of unworthiness and helplessness.

MANIC EPISODE:
Neurotransmitter imbalance: * 1. Norepinephrine 2. Serotonin

BEHAVIORS COMMONLY ASSOCIATED WITH MANIA

a. Affective: Elation/ euphoria, lack of shame, lack of guilt, humorous, intolerance of criticism, expansiveness, inflated
self-esteem*
b. Physiological: Dehydration, inadequate nutrition, needs little sleep, weight loss*
c. Cognitive: Ambitiousness, denial of realistic danger, distractibility, grandiosity, flight of ideas, lack of judgment. *
d. Behavioral: Aggressiveness, provocativeness, excessive spending, hyperactivity, poor grooming, irritability,
argumentative*

DIAGNOSTIC CRITERIA FOR A MANIC EPISODE: At least 3 of the following for at least 1 week:

1. Delusion of Grandeur – over self-worth, inflated self-esteem


RATIONALE: A defense to mask feelings of depression & inadequacies
2. Insomnia
3. Flight of ideas
4. Excessive involvement in pleasurable activities without regard for negative consequences
5. Flight of ideas – talkative/pressured speech/pressure to keep talking
Tell manic pt to speak more slowly to make a sense if he keeps on moving one subject to
another.

6. Hyperactive & Distractibility


8. Easily Agitated
9. Manipulative
10. Increased Metabolism
11. Poor impulse control – impulsive
12. Violent/aggressive/hypersexual
13. Pressured speech

NURSING DIAGNOSIS:

1. Risk/ Potential for Injury directed to others /or to self


2. Fluid & Electrolytes Imbalances
3. Fluid Volume Deficit

NURSING INTERVENTIONS:

1. Accept client; reject behavior


2. Provide consistent care
3. Set limits of behavior/external controls
*One staff to provide controls
*Do not leave alone in room when hyperactivity is escalating
*Explain restrictions on behavior
*Do not encourage performance/jokes
*Approach in a calm, collected, non-argumentative manner
4. Distract and redirect energy: Choose physical activities using large movements until acute mania subsides (dancing, walking
with staff)
Meet nutritional needs: High-calorie FINGER FOODS and fluids to be carried while moving. Prone to become fatigue, so, give finger
foods: potato chips, bread, raisin, and sandwich. SHORTCUT: ALL HIGH CALORIC & HIGH CARBOHYDRATE DIET or ALL
BAKERY PRODUCTS!!!

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 32


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

Tuna sandwich & apple are appropriate food for bipolar manic
A Husband of 36 y/o bipolar manic type says, “My wife hasn’t eaten or slept for days.” The RN
should place a priority focus on physical condition.
Encourage rest: Sedation PRN, short PM naps
7. Avoid ACTIVITIES that increases attention span such as chess, bingo, scrabble...
8. Avoid CONTACT SPORTS: Basketball, gym, strenuous activities & Increase perspiration!!
ACCEPTABLE ACTIVITIES: Brisk walking, punching bag, raking leaves, tearing newspaper.
9 Productive activities: Gardening, finger painting, household chores,
Activity for Manic Bipolar includes raking leaves (quiet physical, constructive, productive) to
increase self-esteem;
competitive is not safe.
10. Less environmental stimulus: No bright lights, do not touch
11. Encourage OFI: Because of Lithium and increased metabolism
12. Check Lithium intoxication
SELECTED SITUATIONS AND INTERVENTIONS:

A. Disturbing the Group Session


1. Separate the patient from the group, REMEMBER don’t touch the patient
Touching the patient may increase AGITATION.
2. Setting of limits – “matter of fact” (#1 Attitude therapy for manipulative patients)
Patient in acute manic phase begins to disrobe, appropriate nursing action
includes removing patient
from group meeting & accompany him to his room

B. Aggressive Reaction
1. Decrease environmental stimulation
A pt who is pt watching TV suddenly throws the pillows & chair, immediate action
is to place pt in seclusion.
“Staff 1st used a lesser means of control for less success.” Shows a documentation
that indicates a pt’s right is being safeguarded during aggressive reactions.

C. Violent Patients
1. Move to the door fast and call the crisis management team

D. Swearing
1. Setting of Limits
2. Give avenues for verbalization/expression vs. Physical violence

MOOD STABILIZERS (ANTIMANIC DRUGS): LITHIUM

For: (Mood disorder specifically Mania (Bipolar Disorder)


USES: Elevate mood when client is depressed; dampen mood when client is in manic; used in acute manic, bipolar
prophylaxis; ACTS by reducing adrenergic neurotransmitter levels in cerebral tissue through alteration of sodium transport → affects a shift in
intraneural metabolism of NOREPINEPHRINE

Action: ↓ hyperactivity and balance or stabilize the mood


Effect: 1 wk.

CODE: LITH

Lithium CO3 – Eskalith, Lithane, Lithobid


Lithium Citrate – Cibalith - S

Therapeutic Serum Level:


= 0.5-1.5 mEq (local/CGFNS)
= 0.6 – 1.2 mEq (NCLEX)
a. Early in therapy: Serum levels measured q 2-3 times per week; 12 hours after the last dose. Long-term: q 2-3 months. Before
lithium is begun baseline RENAL, CARDIAC, and THYROID status obtained.

Antidote: 1. DIAMOX (ACETAZOLAMIDE) carbonic anhydrase inhibitor (for open angle glaucoma)
2. MANNITOL (Osmitrol) osmotic diuretics  Action to ↑ urine output, ↓ cerebral edema
3. MNGT. OF OVERDOSE: Induce emesis / lavage; airway; dialysis for severe intoxication
4. . If patient forgets a dose, he may take it if he missed dosing time by 2 hours; if longer than 2 hours, skip the dose
and take the next dose. NEVER DOUBLE A DOSE!!!

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 33


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

Nursing Considerations:
1. Before extracting Lithium serum level  Lithium fasting 12 hrs  check vital signs
2. Avoid diuretics to prevent hyponatremia
3. Avoid strenuous exercise/activities  gym works
4. Avoid sauna baths
5. Avoid caffeine  because it is a diuretic
6. For hypernatremia  AVOID Na CO3
7. Avoid taking soda and/or soda drinks
8. ↑ OFI – 3 L /day; ↑ Na – 3mg/day
A patient who is talking lithium must be placed in a normal sodium (3 gms.) , high fluid diet (3 L
of water). This is done to facilitate excretion of lithium from the body.

A. Increase Na = ↓ Lithium effect


For hypernatremia  AVOID Na CO3
Avoid taking soda and/or soda drinks
When the lithium level falls below 0.5, the patient will manifest signs and symptoms of
mania.

B. Decrease Na = ↑ Lithium intoxication  MORE dangerous!!!!


AVOID the 2 dangerous “D”: diuretics & dehydration
Avoid diuretics to prevent hyponatremia
Avoid strenuous exercise/activities  gym works
Avoid sauna baths (EXCESSIVE PERSPIRATION)
Avoid caffeine  because it is a diuretic

Stages in Lithium Intoxication

I. Early/Initial/Mild: 1.5 mEq


- Nausea, vomiting & anorexia
- Diarrhea
- Gross hand tremors
- Abdominal cramps  hypocalcemia  metabolic alkalosis
(Prolong vomiting  metabolic acidosis)

II. Moderate: 1.6 – 2.4 mEq


Symptoms are 2x the initial signs

III. Severe: ↑ 2.5 mEq


1. Nystagmus, tactile, olfactory & visual hallucination
2. POA (Polyuria, Oliguria, Anuria)  ARF (Kidney problem)
Lithium is nephrotoxic & teratogenic
3. Grand Mal Seizure  Cerebral hypoxia  ↓LOC  COMA  death

PSYCHOSOMATIC / SOMATOFORM DISORDERS

A. PSYCHOSOMATIC DISORDERS: Without any organic or REAL physiological “OBJECTIVE” symptoms.


• Emotional stress may exacerbate or precipitate an illness.
• The way an individual reacts to stress depends on his physiological and psychological make-up.
• Structural changes may take place and pose threat to life.
• Defense mechanisms include REPRESSION, PROJECTION, CONVERSION and INTROJECTION.
• Synergistic relationship exists between repressed feelings and overexcited organs.
• Somatoform disorders result in impaired social, occupational and other areas of functioning.

PSYCHOPHYSIOLOGIC DISORDER: with real symptoms!


Physical symptoms whose etiologies are in part precipitated by psychological factors and may involve any organ system.

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 34


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

• Cardiovascular: Hypertension, Tachycardia


• Gastrointestinal: Peptic Ulcer, ulcerative colitis, Colic
• Respiratory: Asthma, Hyperventilation, Common colds, Hay fever
• Skin: Blushing, Flushing, Perspiring, Dermatitis
• Nervous: Chronic fatigue, Migraine headaches, Exhaustion
• Endocrine: Dysmenorrhea, Hyperthyroidism
• Musculoskeletal: Cramps
• Others: Obesity, hyperemesis gravidarum

NURSING CARE: Holistic or TOTAL – physical and emotional


Understand that PHYSICAL SYMPTOMS ARE REAL and that the client is not faking and the TREATMENT OF PHYSICAL
PROBLEMS DOES NOT RELIEVE EMOTIONAL PROBLEMS Develop nurse-client relationship:
• Respect the client and his problems.
• Help to express feelings, Allow client to feel in control
• Let client meet dependency needs.
2. Help to work through problems and learn new coping mechanism.

TYPES OF SOMATOFORM DISORDERS / PSYCHOSOMATIC DISORDERS

1. CONVERSION DISORDER: Presence of physical symptoms with NO identified


physical etiology.
CHARACERISTICS: #1 Sign “ Labelle Indifference”
a. Can take the form of blindness, deafness, paralysis or any other physical conditions but with no organic basis.
b. Client derives primary and secondary gains from the physical symptoms.

ASSESS FOR: TWO GAINS IN CONVERSION DISORDER


Primary gain.
REPRESSION: Keeps internal need or conflict out of awareness.
SYMBOLISM: Symptom has symbolic value to client.
Secondary gain. (Not connected to the primary gain)
Additional advantages: Sympathy, attention, avoidance.
Reinforces maladjusted behavior.

NURSING INTERVENTION:
Do’s: Divert attention from symptom; Provide social and recreational activities; Reduce pressure on client; Control
environment
Don’ts: Confront client with his illness; Feed into secondary gains through anticipating client needs.

2. HYPOCHONDRIASIS Preoccupation with an imagined illness with no observable symptoms and no organic changes.
#1 Sign is “DOCTOR SHOPPING”: Inability to accept reassurance even after exhaustive testing activities as going from
doctor to doctor to find cure.

ASSESS FOR
• Preoccupation with body functions or fear of serious disease misinterpretation and exaggeration of physical symptoms
• Adoption of sick role and invalid life-style; signs of severe regression
• Lack of interest in environment history of repeated absences from work
• If the client is MALINGERING: Deliberately making up illness to prolong hospitalization; ‘faking illness’

Nursing Intervention:
• Show acceptance of the client.
• Prepare for, assist in complete medical workup to reassure client and rule and medical problems
• Psychotherapy, family therapy and group therapy:
A combination of somatic and behavioral treatment modalities facilities treatment of the disorder.
o Meet physical needs giving accurate information and correcting misconception.
o Demonstrate friendly, supportive approach but NOT focusing on the illness.
o Provide diversionary activities that build self-esteem.
o Help client refocus on topics other than the illness.
o Assist client understand how he uses illness to avoid dealing with his problems.
DEFENSE MECHANISMS IN SOMOTOFORM DISORDERS: Denial, Projection, Conversion, and Introjection

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 35


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

DISSOCIATIVE DISORDERS

A. DEFINITION: Psychiatric disorder involving disruption in the usually integrated functions of consciousness, identity, memory, or
perception of the environment; Client attempts to deal with anxiety by BLOCKING certain areas out of the mind or deeply
REPRESSING traumatic events, or by PSYCHOLOGICAL RETREAT from reality; A condition NOT of organic origin and usually
occurs as a result of some very painful experience
B. ASSESSMENT FINDINGS:
• AMNESIA: Selective or generalized and continuous loss of memory
• FUGUE: State of dissociation involving amnesia and actual PHYSICAL FLIGHT – transient disorientation where client is unaware
that he has traveled to another location (Client does not remember period of fugue.)
• DEPERSONALIZATION: Alteration in perception or experience of self, sense of detachment from self, as if self is NOT REAL
• DISSOCIATIVE IDENTITY DISORDER ( MULTIPLE PERSONALITY): Donated by two or more personalities, each of which
controls the behavior while in the consciousness
C. NURSING IMPLEMENTATION:
• Assess what form the dissociative disorder is manifesting and degree of interference in ADL, lifestyle, and interpersonal relations
• Reduce anxiety-producing stimuli
• Redirect client’s attention away from self; increase socialization / diversional activities
• Support modalities of treatment:
o Abreaction: Assisting in the recall of past, painful experiences
o Hypnosis; cognitive restructuring
o Behavioral therapy
o Psychopharmacology: Anti-anxiety, antidepressant

Most appropriate intervention for Dissociative Personality Behavior includes encouraging to


chart
alternative personality.

PERSONALITY DISORDERS

A. DEFINITION: Borderline state of personality characterized by defects in its development or by pathologic trends in its structure;
premorbid personality of individuals resembling the compensatory mechanisms associated with the pathologic counterpart.

B. PREDISPOSING FACTORS & CAUSATION


1. Biological predisposition  malnutrition, neurologic defects & congenital predisposition
2. Development of maladaptive behavior
3. Freudian fixation

GENERAL CHARACTERISTICS:
1. Denial
2. Maladaptive behavior  inflexible
3. Minor stress poor tolerance  mood disturbance
4. in reality
5. Not caused by physiological pattern
- Attitude  can be changed
- Immature
- do not adjust to environment

3 CLUSTERS OF PERSONALITY DISORDERS


1. Cluster A Disorders: Odd / Eccentric
a. Paranoid b. Schizoid c. Schizotypal
2. Cluster B Disorders: Dramatic / Erratic
a. Histrionic b. Narcissistic c. Antisocial d. Borderline
3. Cluster C Disorders: Anxious/ Fearful
a. Dependent b. Avoidant c. Passive Aggressive d. Obsessive Compulsive

CLUSTER A: ODD / ECCENTRIC

A. Paranoid Personality Disorder

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 36


PRO Review Soultions and Tutorial Diagnostics
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CHARACTERISTICS: Code (MOST OF THEM STARTS WITH LETTER “P”)


- suspicious, distrustful  oral fixation
- Loneliness  suspicious/mistrust  pathologic jealousy, hypersensitive
#1 DEFENSE MECHANISM: Projection
#1 NURSING DIAGNOSIS: Social Isolation
#1NURSING CONSIDERATION/INTERVENTIONS:
1. Passive Friendliness  no eye contact, mo touch, no laughing/giggling, non whispering
2. Consistency
3. Proxemics: 7 feet away from the patient

B. Schizoid Personality Disorder


CHARACTERISTICS:
- Socially distant, detached, low IQ
- introvert, loner, aloof, humorless
- avoids close relationships with family, friends, peers
- Flat affect  indifferent to praise
- Functional when works alone; more interested on objects
Shy, introverted since childhood but with fair contact with reality
Autistic thinking, dreaming, emotional detachment, avoidance of meaningful interpersonal relationships, cold and detached
#1 NURSING DIAGNOSIS: Social Isolation\

C. Schizotypal Personality Disorder


- Similar with schizophrenia
CHARACTERISTICS:
- Odd, eccentric, lowest IQ
- Magical thinking, e.g., superstitiousness, telepathy
- Ideas of reference or delusion of reference
- Cold/aloof  limit social contact=social anxiety
- Peculiarity in speech but no looseness of association
- may develop into schizophrenia or other psychotic disorders
- Withdrawn, unattached, odd and eccentric,
- Diminished affective (blunted/inappropriate affect) and intellectual skills, vague, over elaborate speech
- Frequent part of vagabond or transient groups of society
#1 NURSING DIAGNOSIS: Social Isolation

CLUSTER B: DRAMATIC/ ERRATIC

A. Antisocial Personality Disorder


- 15-40 y.o, mostly in males
- History of conduct disorder (6-11 yo)

THEORIES: Genetic/hereditary
Physical/Sexual abuse
Low socioeconomic status  maladaptive behaviors
CHARACTERISTICS:
- Impulsive, aggressive, manipulative
- Low self-esteem
- lack remorse
- hates rule/regulations, authority figures
- coprolalia (bad words)
- Kills, cheats, steals, rapes, destroys
- #1 Defense Mechanism: Rationalization
- Underdeveloped superego; lack of guilt, conscience and remorse; unable to learn from experience or punishment
- Life-long disturbances that conflict with laws and customs
- Unable to postpone gratification, immature, irresponsible
- Randomly acting out aggressive egocentric impulses on society; reckless, unlawful, disregard for right of others.
- Steals, cheats, lies
- Appears charming, intellectual, smooth talker
- Antisocial patients have low tolerance to frustration.

NURSING INTERVENTION/CONSIDERATION:
1. SETTING OF LIMITS – “matter of fact,” voice not high nor low, does not say please.

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 37


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

Setting of limits prevent the patient from manipulating the nurse.


2. Consistency is a must regarding rules & regulation.
Efficacy of treatment is achieved for an antisocial if the patient is able to respect
nurse’s & other patients boundaries.
Positive outcome for antisocial personality disorder includes adherence to rule of hospital unit
Interventions that can be appreciated by antisocial include exchanging tokens for any
privilege

B. Borderline Personality Disorder

- Mostly in females

THEORIES: Faulty parent-child relationship; dysfunctional family


Trauma; physical/sexual abuse (18 months)  low ego
Unfulfilled need of intimacy

CHARACTERISTICS:
- Impulsive, self-destructive, unstable
- Self-mutilation & suicidal
Therapeutic measure to prevent self-mutilation in borderline includes behavioral contract.
The purpose of behavioral contract in borderline is to limit use of unhealthy defense
mechanisms
- Unpredictable behavior (gambling, shopping, sex, substance abuse)
- Disturbance in self-concept: Identity
- #1 DEFENSE MECHANISM: Splitting
“You’re the only nurse who understands me.” This statement is shown in a patient with
borderline behavior.
- Identity disturbance with chronic feelings of emptiness (Anhedonia)
- Marked mood swings and impulsive unpredictable behavior with potential
for self-destruction.
- Intense, brief, unstable interpersonal relationships with impulsiveness,
manipulation, physical fights and temper tantrums
A borderline patient indicates an improvement when she state, “I ran around the block
rather than cutting myself”.
Borderline personality with a history of cutting her wrist shows an intense & a changeable
affect during the middle phase of nurse-pt relationship. The patient says, "You’re a smart
nurse. I want to be just like you.” This statement shows Transference
A patient borderline state, “You’re a phony. You don’t know what happened to me.”
Best response of the nurse will be, “I’ll ensure what is necessary will be done to you
Intervention for borderline d/o includes setting of limits through saying, “The policy of the unit
is that, ‘You can’t
leave in the unit in 1st 24 hrs.’”

C. Histrionic Personality Disorder


- More common in women, 2-3 % of the population

THEORY: Llacks Electra complex (no father figure)


Papa’s girl

CHARACTERISTICS:

- Emotional, dramatic, theatrical


- wants to be the center of attention
- Manipulative, Sexually seductive or provocative
- Exaggeration of emotion, Style of speech is excessively impressionistic
- Labile emotion, Positive: Creative, imaginative
- Extroverted, manipulative, vain with behavior directed toward gaining attention to self; - Emotionally unstable; uses somatic
complaints to avoid responsibility

D. Narcissistic Personality Disorder


- Usually Men
- Another: Metrosexual

CHARACTERISTICS:
- Vanity in personal appearance
- Exaggerated or grandiose sense of self-importance
- Boastful, egotistical, superiority complex
- preoccupied with fantasies: Power, success, beauty

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 38


PRO Review Soultions and Tutorial Diagnostics
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- Excessive admirations; envies other, arrogant, lack of empathy


-Overblown sense of importance, grandiosity; with strong need for attention and admiration from others

CLUSTER C: ANXIOUS / FEARFUL

A. Obsessive –Compulsive Personality Disorder


- More in women
- Obsession – irresistible thought, Compulsion – irresistible action

THEORIES: Genetic: Serotonin imbalance


Anal fixation  strict toilet training
Overpowering mother

CHARACTERISTICS:
- Cardinal Signs: RITUALISTIC
- #1 DEFENSE MECHANISM: Undoing, Repression, Symbolization
# 1 Ritual: handwashing

Other Ritualistic behaviors: 4 C’s:


Controlling  perfectionism
Collects or hoarding
Cleaning
Checking

• Rigid, over-conscientious, perfectionist, inflexible, cold affect


• Driven by obsessive concerns
• Sets high standards for self and others
• Preoccupied with details, rules and organization

STEP TO STEP PRIORITY NURSING DIAGNOSIS:


Altered Sleeping Patterns
Altered Skin Integrity
Ineffective Individual Coping

PRIORITY NURSING INTERVENTIONS:


1. Give appropriate time to do rituals to decrease anxiety
In OCD, intervention includes giving an extra ½ hr to the pt to do the ritual before starting
the task.
Question most likely to elicit response for treatment of compulsive hand washing
includes asking “how much has the symptom interfered with your daily activities?”
2. Do not abruptly stop rituals
3. Setting of limits  avoid manipulative and controlling behaviors
4. TX: Tricyclics – antidepressants  balance serotonin and norepinephrine
Effects: 2-4 wks.
Clomipramine (Anaframil) #1 drug of choice for OC
Imipramine (Toframil) 2nd drug of choice

An oriented group therapy is indicated for OCD

B. Dependent Personality Disorder


- Most common personality disorder for Acute wife battering syndrome
- Co-dependency  enabling
Statement of pt that indicates ability to care for self after being victim of domestic
violence includes a statement like, “I have a car key & money hidden outside the
house.”
Battered wife should be referred to shelter

Batterers are violent, loving & remorseful (dual personality)


Wife batterer has low-self esteem
Honeymoon episodes in acute wife battering syndrome showing statement of
reconciliation includes, “Mama, pls. get these red flowers. I love you & I’ll never do it
again.”

CHARACTERISTICS:
- Submissive, clinging

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 39


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

- lacks self-confidence, low self-esteem, helpless, good follower


- Lacks self-confidence, helpless when alone, preoccupied with fear of being alone
- Fails to make decisions and accept responsibility→ induces others to
take responsibility
A pt with Dependent personality who shows ineffective decision making should have
setting of limits & make behavioral contract on its daily activities.

C. Avoidant Personality Disorder

CHARACTERISTICS:
- Shy, timid, inferiority complex
- avoid open forum
- Over sensitive to rejection/criticism
- Social withdrawal = inept
- Depression, anxiety, anger are common
- Withdrawn, loner, lacks self-confidence; with feelings of discomfort/timidity
when with others
-Unwilling to get involved with others and in situations where negative evaluation, rejection and failure are a possibility

C. Passive Aggressive Personality Disorder

CHARACTERISTICS:
- insecure  backbiter  plastic
- loves to procrastinate, cant finish a task
- Patients with passive-aggressive personality expresses anger through passivity.
#1 Defense Mechanism: Reaction formation
.
Goal of nurse in Passive Aggressive Personality includes verbalization of anger when
needed
Goal of Care for Passive Aggressive includes verbalization of feelings of anger when the
need arises.

COGNITIVE / ORGANIC MENTAL DISORDERS

I. COGNITIVE/PSYCHIATRIC DISORDERS
• With organic etiology
• With deficits in COGNITION and MEMORY
• Effects: Changes in levels of functioning and disturbed behavior
• MOST COMMON AREAS OF DIFFICULTY (JOCAM)
J – Judgment (impaired)
O – Orientation (confused/disoriented; illusion/hallucination)
C – Confabulation (filling in memory gaps)
A – Affect (mood changes, depression, tearful, withdrawn)
M- Memory (Impaired especially for names and recent events – compensated by confabulation and circumstantiality)

DELIRIUM VERSUS DEMENTIA

Delirium Dementia

Acute in onset Chronic / Gradual in onset


Reversible irreversible
#1 sign: Clouding of consciousness #1 Sign: Progressive memory
Or grand mal / tonic-clonic seizure Loss

Causes: Hyperthermia, sepsis such as Causes:Unknown (idiopathic)


Encephalitis, meningitis, drug induced
Withdrawal (alcohol & cocaine withdrawal)

SYMPTOMS OF DELIRIUM

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* Difficulty with attention


* Easily distractible
* Disoriented
* May have sensory disturbances such as illusions,
Misinterpretations or hallucinations
* Can have sleep – wake cycle disturbances
* Changes in psychomotor activity
* May experience anxiety, fear, irritability, euphoria,

TYPES OF DEMENTIA

Pick’s Disease: Similar picture to DAT, but with frontal lobe symptoms (personality changes) and reactive gliosis.

Vascular/Multi-infarct Dementia: Patchy cognitive deterioration (dependent on infarct site) appearing within 1 years of vascular injury; common
in men and earlier in onset.

Huntington’s Disease: Autosomal dominant (chromosome 4) disorder with both motor (chorea, gait disturbance, slurred speech) & cognitive
changes (dementia)

Creutzfeldt-Jacob Disease: Dementia due to prions (infectious particle without DNA or RNA); rapidly progressive from vague somatic complaints
to ataxia, dementia then death.

Parkinson’s Disease:
 Dopamine in the basal ganglia & extra-pyramidal system causes tremors (pill-rolling & resting), bradykinesia, cogwheel rigidity,
shuffling gait, mask-like fascies.
 Progresses to depression & dementia, treated with L-dopa

Nursing care for the patient with dementia is geared towards maintaining existing functions by
minimizing regression.
Place an alarm signal to know that the pt is attempting to exit in a dementia client who used to
wander away from acute facility.

ALZHEIMER’S DISEASE

 Degenerative disease of the central nervous system characterized by premature senile retardation. Degenerative disorder of the cerebral
cortex.
 The etiology of Alzheimer’s disease is unknown
 The most common non- traumatic cause of dementia is Alzheimer’s disease at 65, 10% of the population has Alzheimer’s; by 85, the
percentage increases to half. Multi-infarct dementia is the second most common cause of non – traumatic dementia.

 NATURE: Gradual, progressive; Onset: Usually after 65 (2-4%); may begin at 40-65; may die within 2 yrs or 8-10 yrs if with total care.
The main pathology is the of presence of senile plaques that destroys neurons leading to decreased acetylcholine.

 The primary need of a patient with Alzheimer’s is Reorientation.

4 CARDINAL SIGNS OF ALZHEIMER’S

1. Agnosia – sensory–inability to recognize objects/subjects


Patient with agnosia is unable to recognize persons.
1st to forget: The name of an object
2nd to forget is the function of an object
2. Apraxia – sensory-inability for purposeful mov’t. ex. Tremors
3. Amnesia – 1st amnesia to appear: Anterograde amnesia –recent memory
2nd amnesia to appear: Retrograde – past
Tx: Reminiscing Group Therapy
4. Aphasia – sensory-inability for speech and communication

Predisposing/Contributing Factors: Psychiatric Mental Health Nursing 3rd edition by Mary C. Townsend
Exact cause unknown but several hypothesis were introduced; (pg 342-343)
1) Acetylcholine Alteration: Decrease in acetylcholine reduces the amount of neurotransmitter which results in disruption of cognitive
process.

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PRO Review Soultions and Tutorial Diagnostics
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2) Accumulation of Aluminum: Studies show that aluminum accumulates in damaged areas of the brain.
3) Alterations in the Immune System: Antibodies are being produced in the brain which causes a reaction against self it is called autoimmune.
4) Head Trauma: Head injuries
5) Genetic Factor: Pattern of inheritance

THREE STAGES OF ALZHEIMERS

Early stage (Forgetfulness Stage: Mild)

The first symptom of Alzheimer’s disease is Progressive memory loss. This is followed by disorientation, personality changes, language
difficulty, and other symptoms & dementia.
The patient can compensate for the memory loss but the family may notice personality changes and mood swing. Recent memory is affected
including the ability to learn new information. Managing daily living activities becomes progressively more difficult. The patient may notice
difficulty balancing his checkbook and may forget where he put things. Forgetfulness: loose things; forget names, short-term memory loss,
and the individual is aware of the intellectual decline. Early Confusion: Symptoms of confusion begins and concentration may be interrupted.
Individual may forget major event in personal history such as birthday of his/her child: experience declining activity to perform task; individual
may deny memory loss. Findings that are observed in the early stages of Alzheimer’s disease are inappropriate affect, disorientation to time,
paranoia, memory loss, and an impaired judgment.

* Response of nursing assistant to an Alzheimer’s patient that Needs Further Teaching includes a statement like, “How many glasses of water
did you drink today?” - Anterograde amnesia.

Middle stage (Wandering Stage/Sundown syndrome)


The patient is increasingly disoriented and completely unable to learn and recall new information. He may wander or become agitated or physically
aggressive. He may have bladder incontinence and may require assistance with activities of daily living. Individual may be unable to recall major
life events even the name of spouse. Disorientation in the surroundings is common and the person may be unable to recall the day, season, and year.
Sleeping becomes a problem. Symptoms worsen in the evening known as “SUNDOWNING.

Late stage (Kluver Bucy like Syndrome)


The patient may be unable to walk and is completely dependent on caregivers. He’s totally incontinent of bowel and bladder. He may even be
unable to swallow and is at risk for aspiration. He’s unable to speak intelligibly. In the late stages of Alzheimer’s disease it is better to go along
with the patient’s reality rather than confront him with logical reasoning. Asking close ended simple questions that relate to his reality is non-
threatening and calming. Note that the nurse’s response in a way that is congruent is the main concern. The individual may not recognize family
members. There may be problems of immobility.

Nursing Diagnosis: Risk for trauma

Nursing Intervention: 1) Milieu Therapy is needed: a CONSISTENT UNCHANGING & FAMILIAR


ENVIRONMENT IS NEEDED to decrease chances of disorientation &
confusion.
In milieu therapy, patients plan and lead activities rather than the staff.
Millieu therapy involves scientific manipulation of the
environment that can influence
improvement patient’s behavior
2) Store frequently used items within reach.
3) Keep bed in unelevated position with soft padding if client has
history of seizure and keep the rails up.
A confused Alzheimer’s patient who gets out of bed several times must be provided with
a safe environment like placing a hand rails for the patient to hold.
Bed of confused Alzheimer’s patient must always have its side rails up.
4) Assign room near nurses’ station.
5) Assist patient with ambulation.
6) Keep dim light on at night. Decrease environmental stimulus.
7) If patient is a smoker, stay with him/her at all times.
8) Frequently orient patient to time, place and situation.
9) If patient is prone to wander, provide an area in which the client is
safe to wander.
10. Family counseling about Alzheimer’s disease includes checking
that pt is wearing ID bracelet when going out at all times
11. Soft restrain may be required if the client is disoriented and
hyperactive as ordered by the physician.

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12. Provision of simple, structured environment, ↓ choices


Consistency and ROUTINE in care to increase security; Brief,
frequent contacts; reinforce reality-oriented comments
Ample time and patience to allow client to talk / complete tasks
using associative patterns to improve recall: simplicity, focusing,
repeating, summarizing.
Allow REMINISCING of past life / exploits / achievements.
Reminiscing helps lessen the patient’s loneliness.
13. Wear the Medical Alert Bracelet – (name, Address, Tel #,
Diagnosis, Medication)
14. Avoid afternoon naps, avoid caffeine, TV & radio remote
15. REMEMBER THE 3 C’s for Alzheimer’s to DECREASE DISORIENTATION: Color,
Calendar, Clock

Nursing Diagnosis: Altered thought process


Nursing intervention: 1) Frequently orient the patient to reality.
Sensory stimulation for elders helps to increase pt’s arousal
2) Keep explanation simple and use face-to-face interaction. Speak slowly and
do not shout. In caring for elderly w/ Alzheimer’s use short & simple words & face him while you
are talking.
3) Discourage rumination of delusional thinking. Talk about real people
and real events.
4) Monitor for medication side effects.
5) Use soft tone, simple sentences, and a slow, calm manner when speaking to a person with Alzheimer’s
disease. If he doesn’t understand you, repeat yourself using the same words. Your nonverbal
communication is more important than your actual spoken message. Don’t a hurried tone, which will
make the patient feel stressed. Move slowly and maintain eye contact.

Nursing Diagnosis: Self-care deficit


Nursing Intervention: 1) Identify self-care deficit and provide assistance.
Urinary incontinence in patient with Alzheimer’s can be controlled
by decreasing fluid intake at night time
2) Allow plenty of time for the patient to perform task.
3) Provide guidance and support for independent actions by talking
the patient through the task.
4) Provide structure schedule of activities that does not change
from day to day.
5) ADLs should follow home routine as closely as possible.
6) Provide client’s nutritional needs, safety and security. .
7. Give foods high in carbohydrates to an Alzheimer’s who refuses
to eat his meal
In an Alzheimer’s caregiver class, the nurse tells the student that the reason why pt’s do not take
a bath is that they cant remember anymore if they have taken the bath already.

Screening Test: MS Brunner and Suddarth (pg 160)


1) Electroencephalography
2) Computed tomography
3) Magnetic Resonance Imaging

Confirmative Test: MS Brunner and Suddarth (pg 160)


Cerebral biopsy after death.
Complication: MS Brunner and Suddarth (pg 158)
1) Infection
2) Malnutrition

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PRO Review Soultions and Tutorial Diagnostics
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Best Drug: Anticholinesterase:Increases ACH (acetylcholine) levels


MS Brunner and Suddarth (pg 160)
Tacrine hydrochloride (Cognex)
Donezepil (Aricept)
Rivastigmine (Exelon)

DRUG STUDY:
No cure or definitive treatment exists for Alzheimer’s disease. However, three drugs, tacrine (Cognex), rivastigmine (Exelon), and
donepizel (Aricept), have been approved by the Food and Drug Administration to improve cognitive function in patients with mild to moderate
Alzheimer’s disease.

Tacrine hydrochloride (Cognex)-monitor patient for liver toxicity


Tacrine hydrochloride (Cognex)-enhances acetylcholine uptake in the brain, thus maintaining memory skills for a period of time.

SUMMARIZED DRUGS USED TO TREAT DEMENTIA

NAME DOSAGE RANGE AND ROUTE NURSING CONSIIDERATION

Tacrine (Cognex) 40 – 160 mg orally per day divided into 4 Monitor liver enzymes for hepatotoxic
doses effects.
Monitor for flu – like symptoms.

Monitor for nausea, diarrhea, and


Donepezil (Aricept) 5 – 10 mg orally per day insomnia.
Test stools periodically for GI bleeding.

Monitor for nausea, vomiting, abdominal


pain, and loss of appetite.
Rivastigmine (Exelon) 3 – 12 mg orally per day divided into 2
doses

Monitor for nausea, vomiting, loss of


appetite, dizziness, and syncope.

Galantamine (Reminyl) 16 – 32 mg orally per day divided into 2


doses

BEST HERBAL DRUG FOR ALZHEIMERS:


Enhancing memory with ginkgo biloba

Ginkgo biloba, a plant extract, contains several ingredients that many believe can slow memory loss in people with Alzheimer’s
disease, Research has shown that ginkgo produces arterial, venous, and capillary dilation, leading to improved tissue perfusion
and blood flow. Adverse effects are uncommon but may include GI upset or using anticoagulants.

EATING DISORDERS

#1 CAUSE: Unknown
#1 Personality Disorder of Eating Disorders: Obsessive Compulsive Personality

THEORIES OF CAUSATION:
1. Behavioral: Attention-seeking by rejecting foods; manipulation to gratify needs
2. Family interaction: Ambivalent feelings towards mother; overprotection, rigidity, lack of personal boundaries and independence; use
of anorexia to avoid interpersonal conflicts. The issue of CONTROL is a central one for the client with anorexia nervosa. It is believed
that symptoms are caused by stressor that the adolescent perceives as a loss of control in some aspect of her life. Controlling intake and
weight gain is a way the client establishes a sense of control over her life.
3. Psychoanalytic: Regression to oral and anal developmental stage to avoid adolescent sexuality and independence
4. Medical: Genetic predisposition, increased catecholamines, hypothalamus dysfunction

ANOREXIA BULIMIA
- Amenorrhea  lanugo - Binge/purge syndrome

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Binge eating: Eating increased amounts of high calorie food in a


short period of time.
-2 binge-eating episodes or more per week for 3 months

- fluctuation of body weight


- ↓ 15-20% ideal weight
There is ACCEPTANCE
Defective defense mechanism: Denial - good prognosis  acceptance
Poor to fair prognosis - Bulimic patients are usually aware of their abnormal behavior.

CHARACTERISTICS
- carbohydrate, ↑ caloric fast foods
CHARACTERISTICS - 4 % are Boys
- vegetarian - young adults
- All are females - loves to cook
- Adolescent 11-17 yo -abuses laxatives/enema
- hoards/collects food - extrovert
- strenuous exercise
- introvert
- Patient’s with eating disorders are usually high
achievers, perfectionist and preoccupied with food.

OTHERS:
Refusal to take meals → dramatic weight loss
Anorexic patients usually suppress their appetite,
which makes it difficult for the nurse to convince
them to eat.
Resistance to treatment; difficulty accepting nurturance & caring
Feelings of loneliness and isolation
Hypotension, bradycardia, hypothermia
Secondary sexual organ atrophy; amenorrhea
Reduced metabolism, reduced hormonal functioning; hypoglycemia;
electrolyte imbalance
Hyperactivity; Constipation; Leukopenia
Skin problem: Hyperkeratosis (overgrowth of horny layer of Complications:
epidermis) - esophageal varices
- dental carries
- callous finger
Complications: - chipmunk face
#1 Cause of death: cardiac dysrrhythmia --. Hypokalemia  ECG 
ST segment depression & Prominent U wave
STEP BY STEP NURSING DIAGNOSIS:
1. F/E imbalance
2. Fluid volume deficit – hypovolemic shock
STEP BY STEP NURSING DIAGNOSIS: 3.Altered Nutrition less than body requirement
1. F/E imbalance
2. Fluid volume deficit – hypovolemic shock
3. Altered Nutrition less than body requirement
4. Altered Body Image
Change of body image causes difficulty in self-
esteem. Long term treatment for
anorexia/bulimia includes outpatient family
therapy sense of control over herself is a
positive outcome in eating disorder.

NURSING INTERVENTION FOR EATING DISORDERS

1. DIETARY THERAPY → restoration and stabilization of nutritional and fluid balance


a. Feedings: Oral, IV or tubes; monitor hydration and electrolytes
An anorexic patient with high urine specific gravity must be encouraged to have an
increase fluid intake
b. Caring and nurturance when possible

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c. Provide education 1) on growth & development and normal nutrition 2) Limit setting: Based on weight gain or loss, grant or
restrict privileges; use behavioral contract to enforce limits
2. ASSESS AND EVALUATE:
• Weight and % of normal body weight loss; weighing 3x a week: Same time, clothing and weighing scale. Limit activity based on
weight gain: For wt. Loss – complete bed rest; gain less than 100 g- with bathroom privileges; more than 200 g- may ambulate in
the hospital
• Eating patterns: Amount, type of foods, time and place of eating, whether food is forced or followed by vomiting; Provide
surveillance 30 min. to 1 hr after meals
• Preventing the patient from using the bathroom for 2 hours after eating, prevents the patient
from inducing vomiting.
• Presence of anemia, hypotension, bradycardia, amenorrhea
• Interpersonal relationships
3. PROVIDE A STRUCTURED ENVIRONMENT that offers safety and comfort and helps DEVELOP INTERNAL CONTROL→ reduces
need to control by self-starvation.
4. Help client accept eating problem and set realistic, attainable short-term goals
5. Provide support is developing better outlets for emotional expression; Encourage outside interests not related to food
6. Provide teaching on therapeutic diet: Balanced, calories restriction to effect WEIGHT GAIN (1-2 pound per week)
7. Offer PRAISE for progress; accept lapses (behavior modification)
8. Instruct and support in behavioral modification program: 1) Control speed of eating – chewing food well; 2) Self monitoring w/ food
diary; & 3) Praise/reinforce compliance
Best discharge plan for anorexic teen includes attending a support group

DRUG ADDICTION/NONALCOHOLIC SUBSTANCE ABUSE

SUBSTANCE ABUSE TERMS AND DEFINITTIONS

TERMS DEFINITIONS

Psychoactive substance A substance that affects a person’s mood or behavior

Continued use of a psychoactive substance despite the


Substance abuse occurrence of
physical, psychological, social, or occupational problems

A range of physiologic, behavioral, and cognitive


symptoms indicating that a person persists in using the
Substance dependence substance, ignoring serious substance-related problems

The body’s physical adaptation to a drug, whereby withdrawal


symptoms occur if the drug is not used

Physiologic dependence

The emotional need or craving for a drug either for its effect or
to prevent the occurrence of withdrawal symptoms

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A compulsion, loss of control, and progressive pattern of drug


Psychological dependence use; characterized by behavioral changes, impaired thinking,
unkept promises to stop usage, obsession with the drug,
neglect of personal needs, decreased tolerance, and
physiologic deterioration

Addiction

Concurrent use of multiple drugs

An altered physiologic state resulting from the use of a


psychoactive drug

Polysubstance abuse
Accidental or deliberate consumption of a drug in a dose larger
than is ordinarily used, resulting in a serious toxic reaction or
death

Intoxication
Tolerance is the need for the increasing amount of a
substance to produce its desired effect. It also refers to the
decreasing effect of the drug.
Overdose

A state whereby the effect of a drug is decreased and greater


amounts are required to achieve the desired effect because the
person has become tolerant to a similar drug

Tolerance

Any factor that increases the likelihood of an event occurring

The ability of one drug to increase the activity of another drug


Cross-tolerance when taken at the same time

Any use of a drug that deviates from medical or socially


acceptable use

Predisposition The coexistence of a major psychiatric illness and a


psychoactive substance abuse disorder

Potentiation An acute situation in which a person experiences a period


of memory loss for actions as a direct result of using drugs
or alcohol

Drug misuse Discontinuation of a substance by a person who is dependent


on it

The process of withdrawing a person from an addictive


substance in a safe manner
Dual diagnosis

The amount of a drug that produces a poisonous effect

Blackout The tendency to relapse into a former pattern of substance use


and associated behaviors

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Withdrawal The return to a normal state of health, whereby the person does
not engage in problematic behavior and continues to meet
life’s challenges and personal goals

Detoxification
Complete abstinence from drugs while developing a
satisfactory lifestyle

Toxic dose Voluntarily refraining from activities or the use of


substances that cause problems in the physiologic,
psychological, social, intellectual, and spiritual arenas of a
person’s life
Recidivism

Recovery

Sobriety

Abstinence

A. ASSESSMENT FINDINGS
● History. Academic or job failures, marital failures, stealing to support habit, personality change, violent acting out
● Physical Examination: Malnutrition; abdominal cramps; diaphoresis, yawning, lacrimation, rhinorrhea 10 hours after the
last opiate injection; needle marks on arms along path of a vein (wearing of long- sleeves); nasal discharge with nasal
septum perforation (cocaine)
● Social: Inability to maintain ADL and fulfill role responsibilities and obligations

B. NURSING DIAGNOSES, POTENTIAL:

● Altered health maintenance/nutrition related to chemical dependence; lack of interest in food


● High Risk for Violence: Directed toward self or others related to feelings of suspicion or distrust; intake of mind-altering
substances; misinterpretation of stimuli
● Defensive Coping related to denial of problem; projection of responsibility or blame; rationalization of failures

NON-ALCOHOLIC ABUSED SUBSTANCES

DRUG SX OF ABUSE/ INTOXICATION SX OF WITHDRAWAL TREATMENT


OPIATE or NARCOTICS: Euphoria → Chills and PERSPIRATION Naloxone (NARCAN) the #1 antidote
A CNS depressant Anxiety → Tremors for Opioids or Narcotic intoxication
can cause decreased Sadness →
blood pressure, Insomnia Narcotic Withdrawal METHADONE for Heroin
pulse, respiration, causes muscle Withdrawal :
and temperature. ache, rhinorrhea,
1. Demerol anxiety
2. Morphine 1st 12-72 hrs:
3. Codeine -sleep disturbances,
4. Nalbuphine piloerection,

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irritability, tremors,
weakness, diarrhea,
muscle spasm (legs),
abdominal pain, VS
changes, decreased
self-esteem,
Marked respiratory depression depression
HEROIN- (Horse, smack, PinpointPupils ,
junk, Smack, Hyperpyrexia
,Horse and Fine China) Ventricular dysrhythmia
Lacrimation (Watery eyes)
RUNNY NOSE
YAWNING
↑ BP
Dilated pupils
Cramps
Muscle SPASM
Nausea, VOMITING
Panic, diaphoresis, and weight
loss/anorexia

ANXIOLYTICS: Slurred speech Respiratory Fatigue Sodium


Minor tranquilizers depression ↓ BP and PR Anxiety bicarbonate → excretion
Valium Ataxia/ impaired coordination Depression Activated charcoal, gastric lavage
Librium Drowsiness ↑ BP and PR
Barbiturates- (Downes, Seizures, Coma Tachycardia
rainbows, pink ladies) ↓ Memory Tremors
Phenobarbital Nembutal Convulsions
Delirium
Hallucinations
Anxiety
Insomnia
STIMULANTS Euphoria Depression Activated charcoal, use gastric lavage
(Upper, meth, speed, pep, Agitation Fatigue
pills, crystal, Ice, ↑ BP, PR, RP, Temp Apathy
Uppers, Crank Hyperactivity, dilated pupils, Disorientation
Amphetamines Grandiosity Irritability
Dexedrine Hypervigilance, Altered sleep
Methamphetamine Euphoria, Appetite suppression,
Personality changes, Antisocial
behavior

Cocaine (Oral, Injected, Nasal septum perforation Cocaine use leads to dopamine
Inhaled) Cocaine is characterized by, deficiency. Amino acid therapy is
“Coke” Irritability, Seizure vivid dreams and hypersomnia utilized to facilitate restoration of
“Crack” Coma, Insomnia, Dilated pupils or insomnia and psychomotor depleted neurotransmitters.
“Snow” agitation.
“Blow” Psychosis similar to paranoid
“Lady” schizophrenia
“Powder”

Hallucinogens: LSD (acid) Hallucination None Small doses of Valium


(PCP :Oral, Injected, Inhaled) Incoherence
Angel dust, Hog, ↑ confusion
rocket fuel) Dilated pupils
↑ BP, Temp
Delirium, Mania, Agitation
Convulsions
Coma
Cannabis #1 sign RED EYES Hyperactivity Most effects wear off in 5-8 hr ‘ talk
Derivatives: (irritated conjunctiva) Insomnia down’ client
Marijuana (mary jane, joint, Fatigue Dry mouth
grass, weed, Pot, Hash, Weed) Conjunctival Sexual arousal
Congestion Visual hallucinations
↑ appetite

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Euphoria
Relaxed inhibition
Dilated pupils
Psychosis

Another word for alcohol is “Booze” “Brew”

GENERAL PRINCIPLES OF CARE: ALCOHOL DETOXIFICATION

3 A’s = Alcohol Withdrawal  Aversion Therapy (Punishment)


Antabuse (Disulfiram) = no effect unless mixed with alcohol
Action: Inhibit Antabuse effect Acetaldehyde dehydrogenase
> Dosage: Acute phase = 500 mg in 1st 2 wks.
Maintenance Phase = 250 mg & ↓
>Prohibited Household items with alcohol: mouthwash, cough syrup/elixir, vinegar, fruitcake, shaving cream, astringent, and
toner, acetone/nail polish
Cough medicines and other over-the-counter medicines are alcohol-based and may cause
antabuse reaction when it is combined with antabuse.
Antabuse may worsen renal damage thus it is contraindicated for patients with renal problems.

Effect of Antabuse with Alcohol

1. Nausea & Vomiting


2. Diarrhea
3. Intense headache
4. Abdominal cramps

> Short term objective for an alcoholic: To stop/cut denial


Long term objective: Abstinence (similar with STD/HIV/AIDS)

> # 1 group therapy for Alcoholics


(12 step recovery program – AA (Alcoholic Anonymous)
for victims of alcoholics: AL-ANON
for alcoholic teens: ALATEEN
Correct response of an RN to alcoholic patient who says, “I don’t want to attend group meeting, I
don’t need their alcoholic advice.” Is a statement like,“ The group activity may not seem helpful to
you but you can help them.”

> Screening Questions for alcohol abuse:


1. When was the last time you have taken alcohol?
2. How much alcohol have you taken for the last 24-48 hrs?
In a detoxification unit, the nurse asks the pt when was the last time he drink alcohol to determine
the onset of alcohol withdrawal syndrome.

Goal in alcohol detoxification includes maintaining maximum physical integrity during withdrawal
period.

Statement of a pt who is alcoholic and undergoing detoxification saying, “I can quit whenever I want.”
shows denial

CAGE SCREENING QUESTION FOR AN ALCOHOLIC


C cut down alcohol (Do you need to cut down alcohol?)
A annoyed (Are you annoyed when someone will ask you “Are you an alcoholic?)
G guilty (Are you guilty of taking too much alcohol?)
E eye opener (stimulant) Do you use an eye opener early in the morning to decrease the after effects of alcohol?

3 Stages of Alcohol Intoxication

I. Alcohol Serum Level = 0.04 -0.05% > unsteady


gait
> ↓ social & sexual inhibition

II. ASL = 0.08-0.1 or 100 mg/dl

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> slurring of speech


> Fruity odor  similar to ketoacidosis
> Legal intoxication

III. ASL = 0.15-0.2 – severe alcohol intoxication

> 4 Common Complications with History of Alcoholism


1. Liver Cirrhosis
2. Gastritis  inflammation
3. Pancreatitis
4. Wernicke’s Korsakoff’s  peripheral neuritis  lack of Vit. B1 (thiamine)
(Sx: Tingling sensation/numbness of extremities: Avoid electric blankets!)
Wernicke’s’ psychosis is due to thiamine deficiency.
Confabulation or making up of stories is one of the initial manifestations of Korsakoff’s
syndrome.

Two categories of Wernicke’s Korsakoff’s:

A. Wernicke’s Aphasia / Receptive Aphasia: Problems in interpretation (temporal lobe)


B. Korsakoff’s Psychosis – irreversible (the best drug is Risperidone (Risperdal): It has
Decrease extrapyramidal symptoms (EPS)
4 Stages of Alcohol Withdrawal

I. Early/Initial – Fine tremors, restlessness, tachycardia, diaphoresis, hyperventilation &


nervousness
Symptoms of alcohol withdrawal is observed when the cup rattles to the side
when the patient stirs his coffee

II. Hallucination – #1 hallucination of Alcohol withdrawal is TACTILE

Nursing diagnosis for patient with delirium tremens who says, “There are bugs in my bed crawling over
me” is Altered Thought Process

2. Visual hallucination
Intervention: > Use lampshade to ↓ shadow (illusions)
Leaving a light on the patient’s room will decrease visual hallucinations, which frequently
occur in
alcohol withdrawal syndromes.
 Shadow stimulates hallucination
 don’t leave the patient (Offering of self)
Assigning a staff to the patient promotes safety especially during withdrawal
episodes.

III. Pre-seizure/RUM FITS

Impending signs of Seizure


1. Epigastric pain (early sign in eclampsia)
2. High pitch cry/projectile
3. Eye pain/periorbital pain (scotomas) usually in eclampsia
4. Headache & Aura- ↑ ICP
5. Restlessness  cerebral hypoxia = ↓ 02 & glucose

IV. Delirium Tremens


Active Seizure = Grand mal/Tonic-Clonic
Delirium tremens is initially manifested by anxiety, restlessness, illusions, hallucinations and elevated
vital signs.
Observation indicating a need to be included during endorsement to next shift in an alcoholic patient
in the ER include observations of becoming fearful (delirium tremens)

DRUGS CAUSING DELIRIUM

Anticonvulsants
Anticholinergics
Antidepressants

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 51


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

Antihistamines
Antipsychotics
Aspirin
Barbiturates
Benzodiazepines
Cardiac glycosides
Cimetidine (Tagamet)
Hypoglycemic agents
Insulin
Narcotics
Propranolol (Inderal)
Reserpine
Thiazide diuretics

MOST COMMON CAUSES OF DELERIUM

Physiologic or metabolic Hypoxemia, electrolytes disturbances, renal or hepatic failure,


hypo- or hyperglycemia, dehydration, sleep deprivation, thyroid
or glucocorticoid disturbances, thiamine or vitamin B12
deficiency, vitamin C, niacin, or protein deficiency,
cardiovascular shock, brain tumor, head injury, and exposure to
gasoline, paint solvents, insecticides, and related substances

Systemic: Sepsis, urinary tract infection, pneumonia


Cerebral: Meningitis, encephalitis, HIV, syphilis

Infection Intoxication: Anticholinergics, lithium, alcohol, sedatives, and


hypnotics
Withdrawal: Alcohol, sedatives, and hypnotics
Reactions to anesthesia, prescription medication or illicit (street)
drugs
Drug-related

COMMONLY USED ANTICONVULSANTS

1. Valium (Diazepam)  best drug for delirium tremens


2. Librium (Clordiazepoxide)
Positive) outcome of Librium in alcoholic depressed woman includes an observation that
client can pick an object on floor w/ smooth coordination
3. Klonopin (Clonazepam) 
4. Phenytoin (Dilantin)  best anticonvulsant for children
SE: Gingival hyperplasia & red orange urine
Intervention: Massage the gums & use soft bristle toothbrush
Adverse Effect: Blood dyscrasia- thrombocytopenia S/SX: Bleeding of the gums
Lab test: Platelet count = 150,000-400,000; if ↓100,000-
active bleeding
Special Considerations: The only COMPATIBLE I.V. Solution for
Phenytoin (dilantin) is NSS (Normal Saline Solution)

5. Carbamazepine (Tegretol): Anticonvulsant  trigeminal neuralgia (tic douloureux)


A/E: Agranulocytosis/neutropenia – S/Sx: Sore throat -
Neutrophils 54-56 %

6. Valproic Acid (Depakene/Depakote) therapeutic serum level: 40-100 mcg.


Adverse Reaction: Hepatotoxic (assess SGPT or ALT)

7. Ethosuccimide (zarontin)

Chlordiazepoxide (Librium), multivitamins, thiamine and folic acid help decrease withdrawal symptoms.

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 52


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

GENERAL PRINCIPLES OF CARE: DETOXIFICATION/OVERDOSE


A. Maintain airway: Intubation (keep airway on hand), suction
B. Start IV line
C. Monitoring: BP, respiration, pulse, temperature, LOC
D. Prevent and control seizures; Keep in calm, quiet environment
E. Check for trauma, protect from injury
A pt taking phencyclidine (PCP), shouts & walks back & forth, appropriate nursing intervention
includes seclusion, staying w/ the pt, and decreasing stimuli.
F. Administer ordered drugs; Detoxify / treat overdose-
 NALOXONE (NARCAN) – Pure antagonist to narcotics-induces withdrawal and stimulates respiration; DRUG OF CHOICE when in
doubt the substance used because NALOPHINE (NALLIN), a partial antagonist to narcotics, will ↑ respiratory depression if
barbiturates have also been used
 METHADONE – drug substitute used for acute withdrawal and long-term maintenance; changes an illegal to a legal drug, which is
administered under supervision.
 Antidepressants block the ‘high’ from stimulant abuse
G. Nutrition: High-calorie, high-protein, high-vitamin

SEXUAL DISORDERS / DYSFUNCTION

A. SEXUAL DISORDER: Deviations in sexual behavior; sexual behaviors that are directed toward anything other than consenting adults or are
performed under unusual circumstances and are considered abnormal
B. PARAPHILIA: Sexual fantasies or urges that are directed toward nonhuman objects, the pain to self or partner, or children and other
nonconsenting individuals.
1. EXHIBITIONISM: Sexual gratification from exposing genitalia
2. FETISHISM: Sexual gratification from an inanimate object (usually clothing material) substituted for the genitals
3. FROTTEURISM: Sexual gratification from toughing or rubbing against a nonconsenting person (usually in crowds, public
transportation)
4. MASOCHISM: Sexual gratification from self-suffering used as an accompaniment of the sexual act or substitute for it
5. PEDOPHILIA: Sexual gratification from children
6. SADISM: Sexual gratification from inflicting pain or cruelty to others used as an accompaniment of the sexual act or a substitute for it
7. TRANSVESTISM: Sexual gratification from wearing clothes of the opposite sex
8. VOYEURISM: Sexual gratification from watching the sexual play / act of others
9. ZOOPHILIA: Sexual gratification from animals
C. SEXUAL DYSFUNCTION: Generalized or situational, acquired or lifelong inhibition or interference with any of the phases of the sexual
responses which may be due to psychogenic factors alone or psychogenic and biologic combined.
D. NURSING DIAGNOSES
1. Anxiety related to threat to security and fear of discovery
2. Anxiety related to conflict between sexual desires social norms
3. Sexual dysfunction related to actual or perceived sexual limitations
4. Sexual dysfunction related to inability to achieve sexual satisfaction without the use of paraphilic behaviors
5. Potential for infection related to frequent changes in sexual partners or sadistic or masochistic acts
6. Potential for injury / violence related to sexual behavior and retaliation for sexual behaviors

E. GENERAL PRINCIPLES OF CARE


1. Acceptance NOT of the behavior but of the client who is in emotional pain
2. Protection of the client from others
3. Setting limits on the sexual acting out
4. Supporting of self-esteem: Avoidance of punitive remarks or responses
5. Provision of diversional activities

PERVASIVE DEVELOPMENTAL DISORDERS


CODE: ACA
Autism, Conduct Disorder, Attention Deficit Hyperactive Disorder (ADHD),

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 53


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

AUSTITIC DISORDER

A. A type of developmental disorder for an unknown; probable underlying problem: failure to develop satisfactory relationships with significant
adults
- mostly males
- talented in music or math
- # 1 screening test – DDST (Denver Developmental Screening Test)
- Autism is usually diagnosed during the toddler stage.
CHARACTERISTICS:
1. Blank stare
2. Repetitive movement: head banging  padded room/helmet
3. Likes to follow bright moving objects
4. Catatonic
5. Temper tantrums
6. Clings to inanimate objects
B. ASSESSMENT FINDINGS:
1. Disturbance in sense of self-identity, in ego system formation: Inability to distinguish between self and reality / environment → speaks of
self in the third person
2. Withdrawal from reality.
3. Lacks meaningful relationship with outside world; turns to inanimate objects and self-centered activities for security
4. Personality alteration – adaptive, inhibitory, steering mechanisms due to profound interference in intellect
5. SEVERE AUTISM – Severe apathy, Association looseness, Autistic thinking, Poor grasp of reality, Ambivalence, Poor communication
skills, Poor interpersonal relations, Poor intellectual functioning
C. NURSING DIAGNOSIS: Potential for Injury

D. NURSING IMPLEMENTATION:

1. Provide consistent, routine ADL in familiar environment


2. Set consistent and firm limits for his behavior
3. Make physical contact on a regular basis. Accept the client’s need to push but still maintain regular contact.
4. Prevent acts of self-destructive behavior
5. Provide appropriate therapy:
● Removal from home, if necessary; consistent loving home care is still favored over hospitalization; consistent care giver; never
leave alone; and always provide safety.
● Psychotherapy: Play, group, individual therapy
Primary treatment goal to facilitate the recovery of an autistic child should include playing
with blocks not with balls .
Occupational Therapy #1  behavior modification #2
Behavior modification in an autistic child enables the nurse to modify the child’s maladaptive
behavior.
● Pharmacology: Tranquilizers and amphetamines to reduce symptoms
Caring autistic children requires specialized skills.

ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)


A. Disruptive behavioral disorder evident before 7 years old and lasting at least 6 months and characterized by hyperactivity and inattentiveness

THEORIES: ↑ Norepinephrine, ↑ Serotonin


- #1 Screening Test  DDST

CHARACTERISTICS:
1. Hyperactive  could not sit and stay in 15 minutes
2. ↑metabolism  fatigue
3. handwriting not legible
4. Easily agitated by noise & color (orange/yellow)

B. ASSESSMENT
1. Severe inattentiveness with or without hyperactivity
2. Short attention span
3. Excessive impulsiveness
4. Squirming and fidgeting
5. Hyperactive  could not sit and stay in 15 minutes
2. ↑metabolism  fatigue
3. handwriting not legible
4. Easily agitated by noise & color (orange/yellow)
C. NURISNG IMPLEMENTATION:
1. Set realistic, attainable goals

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 54


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

2. Provide firm, consistent discipline with opportunities to experience satisfaction and success
3. Provide a structured environment-
● With a balance of energy expenditure and quiet time
● With learning experience utilizing child’s ability
● With exercise in perceptual-motor coordination
● With LESS STIMULATION
The priority needs of the child with ADHD are safety and provision of inadequate nutrition.
Catching attention of a child with ADD includes getting him to look at his mom & give him
simple
directions.
4. Administer drugs as ordered: RITALIN (methylphenidate) or dextroamphetamine sulfate

5. #1 Therapy: Occupational Therapy using behavior modification


2. DIET: ↑caloric content – finger foods
3. Vitamin B Complex ↑ appetite
4. Do not mix Caffeinated food/drinks with ACA/alcohol
5. Tx: 1. RITALIN (Methylphenidate: BEST GIVEN AFTER BREAKFAST)
Always with meals
Ritalin, the drug of choice for ADHD causes growth suppression, insomnia and suppression of
appetite.
Psychostimulant – to increase attention span
2. Dextroamphetamine (Dexedrine)
3. Pemoline (Cylert) very hepatotoxic!!!
4. Stratera ( Atomoxetine) newest psychostimulant!!
Contraindication: Do not give below 6 yo  hepatotoxic  SGPT
Stratera, a drug for ADD/ADHD enhances catecholamine effect.
Statement like, “My son is able to accomplish his task better,” indicates efficacy of the drug.

CHILD ABUSE

A. DEFINITION: Physical abuse and emotional neglect; may include sexual abuse
B. CAUSE: Exact-unknown; Present in all socioeconomic levels
C. ASSESSMENT:
● Obvious physical injuries, disturbance on parent-child interaction (Absence of PROTEST on admission of a toddler is a sign of abuse.)
● Inconsistency of declaration of the type, location, cause of injury, discovery of undeclared / unreported fractures
● Malnutrition / failure to thrive / emotional neglect
● Sexual abuse signs: Genital bruises, lacerations; STDs
• History: Parents who were abused as kids
○ Other characteristics of abusive parents: 1) Tend to be young, immature, dependent; 20 Low in self- esteem 3) Lacks identity 4) Expect
child to provide them with love and care (PERSONAL ROLE THEORY of causation) 5) With incorrect concept of what the child is, and
can do 6) With inadequate resources and support system
Abusive parents usually have low-self-esteem and has little social involvement.
Child abuse is common in the lower socio-economic class.
The interaction between the abuse child and a mother provides a clue to the kind of relationship
that this child has with his mother.
In working with the mother of abused child, therapeutic use of self requires self awareness
initially, therefore the nurse has to deal with her feelings first.
Attendance to a parenting class is a step towards learning parenting skills, which are lacking in
abusive parents.

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 55


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

D. POTENTIAL NURSING DIAGNOSES


1) Impaired Skin Integrity 2) Infective Family Coping
E. NURSING IMPLEMENTATION
• FIRST: Meet physical needs; treat injuries
• MANDATORY: REPORTING of suspected cases to appropriate agency (SAVE EVIDENCES; TAKE PICTURES)
Notify the legal authorities about reports of a battered 7 y/o girl is part of the responsibilities
of an RN
• EMOTIONAL SUPPORT to child: PLAY THERAPY to express feelings; NONJUDGMENTAL ATTITUDE toward parents
• ROLE MODELING for parents who are encouraged to care for child
• DOCUMENTATION of ACTUAL FINDIGNS not interpretation nor opinion

POSSIBLE INDICATORS OF ELDER ABUSE

Physical abuse indicators

• Frequent, unexplained injuries accompanied by a habit of seeking medical assistance from various locations
• Reluctance to seek medical treatment for injuries, or denial of their existence
• Disorientation or grogginess indicating misuse of medications
• Fear or edginess in the presence of family member or caregiver

Psychological or Emotional abuse indicators

• Helplessness
• Hesitance to talk openly
• Anger or agitation
• Withdrawal or depression

Financial abuse indicators

• Unusual or inappropriate activity in bank accounts


• Signatures on checks that differ from the elder’s
• Recent changes in will or power of attorney when elder is not capable of making those decisions
• Missing valuable belongings that are no just misplaced
• Lack of television, clothes, or personal items that are easily affordable
• Unusual concern by the caregiver over the expense of the elder’s treatment when it is not the caregiver’s money being spent

Neglect indicators

• Dirt, fecal or urine smell, or other health hazards in the elder’s living environment
• Rashes, sores, or lice on the elder
• Elder has an untreated medical condition is malnourished or dehydrated not related to a known illness
• Inadequate clothing

Indicators of self-neglect

• Inability to manage personal finances, such as hoarding, squandering, or giving away money while not paying bills
• Inability to manage activities of daily living such as personal care, shopping, housework
• Wandering, refusing needed medical attention , isolation, substance use
• Failure to keep needed medical appointments
• Confusion, memory loss, unresponsive
• Lack of toilet facilities, living quarters infested with animals or vermin

Warning indicators from caregiver

• Elder is not given opportunity to speak for self, to have visitors, or to see anyone without the presence of the caregiver
• Attitudes of indifference or anger toward the elder
• Blaming the elder for his or her illness or limitations
• Defensiveness

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 56


PRO Review Soultions and Tutorial Diagnostics
4/F Lola Taya Bldg., Quezon Ave., Q.C. (02)408-7738/0921-3278041

• Conflicting accounts of elder’s abilities, problems, and so forth


• Previous history of abuse or problems with alcohol or drugs.

by Prof. Darius Candelario, RN, RM, US-RN, MAN, MSN 57